Notice Of Eligibility And Rights & Responsibilities (Family And Medical Leave Act) - Colorado State University
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1
2Notice of Eligibility and Rights & Responsibilities
(Family and Medical Leave Act)
Instructions: Complete this eligibility notice the first time in the FMLA year (a rolling twelve (12) month period, measured forward
from the first date the eligible employee uses FMLA Leave to the same date twelve (12) months later) that an employee requests leave
for a particular qualifying reason, and thereafter during the same FMLA leave year, ONLY if the employee’s eligibility status for FMLA
changes. This notice must be given within five (5) business days of the request for leave, or the date you acquire knowledge that the
employee’s leave may be FMLA eligible, absent extenuating circumstances. It is not necessary to complete a new eligibility notice in
the FMLA leave year even if a subsequent FMLA request is for a different qualifying reason (completion of a new “Designation
Notice” is required for documentation purposes). Departments must send copies of FMLA information to the Human Resources
Benefits Unit.
Date of Notification:_______________________________________
(Today's Date)
To: __________________________________________________
Oracle Employee ID #:______________________________
(Employee)
From: ________________________________________________
Department:______________________________________
(Department Representative)
Eligible employees may take up 12 weeks in a rolling calendar year if the event qualifies under the Family Medical Leave Act (FMLA) of 1993 or
the Colorado Family Care Act (CFA). The following explains the rights and obligations under family/medical leave. It also explains the
consequences if you fail to meet your obligations.
On _________________, you informed us that you needed leave beginning on __________________ and ending on _________________ for:
(Date)
(Date)
(Date)
1
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
2
;
domestic partner
2
or
civil union partner
2
;
child
3
;
parent due to
his/her serious health condition.
Because of a qualifying exigency arising out of the fact that your spouse; son or daughter; parent is on covered active duty or call to
covered active duty status with the Armed Forces.
Because you are the
spouse
2
;
domestic partner
2
or
civil union partner
2
;
son or daughter;
parent;
next of kin of a
covered Servicemember with a serious injury or illness.
1
If FMLA is not utilized continuously (12 weeks), intermittent leave must be taken within 12 months from the date of birth or placement of a
child for adoption, and approval of such intermittent leave is at the department’s discretion, unless deemed to be medically necessary.
2
“Spouse” means a person who is legally married to an eligible employee, including a common-law spouse or same-gender spouse when
the applicable jurisdiction’s law recognizes such marriages. “Domestic Partner” is defined under the terms of the University’s benefit
plan. “Civil Union Partner is defined under C.R.S.§14-15-103.
3
”Child” includes the children of a spouse, common-law spouse, same-gender spouse, domestic partner or civil union partner.
This Notice is to inform you that you:
Are eligible for FMLA leave (See below 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 toward this requirement.
You have not met the 1,040‐hours worked requirement.
If you have questions, contact the Human Resources Benefits Unit at (970) 491-MyHR (6947) or view the FMLA poster at
3/2015
Page 1 of 2
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