Jsu Request For Family Medical Leave Act Form (Fmla) Page 2
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2REQUEST FOR FAMILY MEDICAL LEAVE ACT FORM (FMLA)
Family Medical Leave Act Policy 1:02:17
FAMILY MEDICAL LEAVE REQUEST
When the need for sick/medical leave is foreseeable, the employee must apply 30 days in advance, if possible. If the
need for leave is unforeseen, the employee must provide such notice as is practicable (within 1-2 business days upon
his/her return to work, or when the need for leave becomes known). Failure to submit a request for Family Medical
Leave in a timely manner could result in the delay of your request and/or FMLA protections.
You are required to furnish medical certification for a serious health condition for yourself (including pregnancy) or a
family member. You must furnish this certification within 15 days after you apply for Family and Medical Leave. For your
own medical leave, the certification must include information that you are or will be unable to perform one or more of
the essential functions of your job.
If you normally pay a portion of the premiums for health insurance, these payments must continue during the period of
Family and Medical Leave in order to avoid interruption of your benefits.
You are responsible for timely payment of your portion of premiums for health and other benefits you elect to continue
during leave. If you are in a paid status during any part of your leave, usual deductions will be made from your paycheck.
If you are in an unpaid status, you must make arrangements to pay your usual contribution.
You must submit a Return to Work form to the Department of Human Resources completed by your licensed healthcare
provider prior to being restored to employment. If such certification is not received, your return to work may be delayed
until such certification is provided.
While on medical/sick leave, you are not permitted to perform work in behalf of JSU, and may be required to furnish your
supervisor with periodic reports of your intent to return to work.
hrconfidential@jsu.edu
Page 2 of 2
Form 41
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