Form 1003 - Notice Of Eligibility And Rights & Responsibilities (Family And Medical Leave Act)


Notice of Eligibility and Rights & Responsibilities
(Family and Medical Leave Act)
(Form 1003)
In general, to be eligible an employee must have worked for an employer for at least a cumulative total of 12 months within
the past seven years, have worked at least 1,250 hours in the 12 months preceding the leave, and work at a site with at least
50 employees within 75 miles. This form provides employees with the information required by 29 C.F.R. § 825.3000 (b), which
must be provided within five business days of the employee notifying the employer of the need for FMLA leave. Part B
provides employees with information regarding their rights and responsibilities for taking FMLA leave, as required by 29 C.F.R
§825.3000 (b), (c).
Employer Representative
On ________________________, you informed us that you needed leave beginning on ___________________________ for:
The birth of a child, or placement of a child with you for adoption or foster care.
Your own serious health condition.
Because you are needed to care for your___ spouse; ___ Duke registered same sex spousal equivalent; ___ child; ___ parent due to
his/her serious health condition.
Because of a qualifying exigency arising out of the fact that your ___ spouse; ___ Duke registered same sex spousal equivalent; ___
son or daughter; ___ parent is on active duty or call to active duty status in support of a contingency operation as a member of the
National Guard or Reserves.
Because you are the ___ spouse; ___ Duke registered same sex spousal equivalent; ___ son or daughter; ___ parent; ___ next of kin
of a covered service member with a serious injury or illness.
This notice is to inform you that you:
Are eligible for FMLA leave (See PART B below for Rights and Responsibilities).
Are NOT eligible for FMLA leave, because (only one reason need be checked, although you may not be eligible for other reasons):
You have not met the FMLA’s 12- month length of service requirement. As of the first date of requested leave, you will have
worked approximately ___ months towards this requirement.
You have not met the FMLA’s 1,250 hours-worked requirement.
You have exhausted your FMLA entitlement.
You do not work and/or report to a site with 50 or more employees within 75 miles.
If you have any questions, contact ____________________________________________ or view the FMLA policy at or
contact Corporate HR at 919-684-5600.
As explained in Part A, you meet the eligibility requirements for taking FMLA leave and still have FMLA leave available in the applicable 12-
month period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must return the following
information to us by ___________________________. (If a certification is required, employers must allow at least 15 calendar days from
receipt of this notice; additional time may be required in some circumstances.) If sufficient information is not provided in a timely manner,
your leave may be denied.
Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to
support your request___ is /____is not enclosed.
Sufficient documentation to establish the required relationship between you and your family member.
Other information needed: _____________________________________________________________________________________
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Revised April 2014


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