Archdiocese Of Los Angeles Family And Medical Leave Forms Page 11
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13Form B
Archdiocese of Los Angeles
Family and Medical Leave
Notice of Eligibility and
Rights and Responsibilities Notice
Employee’s Name ________________________ Location _____________________ Date _______
A. Notice of Eligibility
Regular full-time and regular part-time employees who are regularly scheduled to work at least 20
hours/week in any job classification and have been employed by the Archdiocese at any Archdiocesan
location for at least 12 months preceding the leave are eligible for FMLA leave.
We received your request (attached) to take leave from ____________ to ____________ and determined
that:
___
You are eligible for FMLA leave. (See Part B for Rights and Responsibilities.)
___
You are eligible to take FMLA, but must provide the following documentation : _____________
______________________________________________________________________________
___
You are not eligible for FMLA leave because (only one reason need be checked):
___
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 are not regularly scheduled to work at least 20 hours/week as required by
Archdiocesan leave of absence policy.
___
You have already taken the maximum leave allowable within the last 12 months.
B. Rights and Responsibilities for Taking FMLA Leave
If your request qualifies as FMLA leave, you will have the rights and responsibilities detailed in the
attached Archdiocesan Leave of Absence Policy including:
•
Archdiocesan policy provides that if you are eligible for leave, you may have up to 4 months (16
weeks) unpaid leave in a 12 month period. The 12 month period is measured forward from the
date your FMLA leave begins, with the following exceptions:
Revised 2013
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