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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).

[PART A- NOTICE OF ELIGIBILITY]

TO:

________________________________________

Employee

FROM:

________________________________________

Employer Representative

DATE:

________________________________________

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.

__________________________________________________________________________________________________________________

[PART B- RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE]

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: _____________________________________________________________________________________

Page 1 of 2

Revised April 2014

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

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