Family & Medical Leave Act (FMLA)

Family & Medical Leave Act (FMLA)

Checklist

(For Department Use)

Employee Name: EmplID: ______

Department: Supervisor: ______

Employee Eligibility:
Employee has worked a total of 12 months for the University of Missouri / oNo / oYes
Employee has worked 1250 hours in the previous 12-month period / oNo / oYes
Employee has used less than 12 weeks/480 hours (26 weeks/1040 hours if leave is for care of an injured service member) of FMLA in previous 12 months / oNo / oYes
Employee eligible for FMLA (if 'Yes' to all of the above). / oNo / oYes
Paid Leave Balances as of Last Day Worked: (Last Day Worked : ______)
Vacation (hours)____ / Sick (hours)____ / Personal (hours)____ / Comp Time (hours)____
FMLA Leave Balances:
FMLA Begin Date (if < 12 months from current absence):______
FMLA Leave available for this absence: ______weeks ______days ______hours
(Date) Process Checklist for employee requesting FMLA
FMLA eligibility letter, notice of rights and appropriate certification form sent to employee
Health Care Provider/Military Exigency/Injured Service Member certification form received
FMLA designation letter sent to employee (FMLA: approved____ denied____)
Department must track FMLA absences (Time and Labor does not have this capability)
Complete Request for LOA (UM Form 108), if leave is continuous and > 30 days
Personnel Action Form (PAF), if leave is continuous and > 30 days
Send completed FMLA letters, certification, and UM Form 108 to Human Resource Services
Verify accruals have been frozen in Time and Labor (Does not apply to intermittent leave)
(Date) Process Checklist for employee returning to work
Fitness for Duty Certification returned (For employee’s own serious health condition)
Personnel Action Form (PAF) to return employee from leave, if applicable
Verify accruals have been activated and adjust as needed in Time and Labor (Does not apply to intermittent leave)

Additional Comments:

Rev. January 2011