Template for Block of Time Family and Medical Leave (FML) approval

  • The letter should be utilized once the unit/college has received a request for block of time FML.
  • The letter shall be issued no later than 5 days after receiving the FML request. Once issued, both employee and unit supervisor should receive a copy of the letter and a copy retained in the employee’s confidential leave file maintained by the HR representative for the unit/college. A copy of the letter should be forwarded to the UIC HR Service Center via an HR Front End (HRFE) Administrative-ADM transaction.
  • Letters should mirror the template below and be placed on unit/college letterhead. [Portions in brackets are to be filled in with the appropriate information. Specific instructions are provided in italics]

[DATE]

[Employee]

[Address]

[City, State Zip code]

Dear [Employee]:

[Department name] received your request for “block of time” Family and Medical Leave (FML) for your[self/spouse/daughter/son/mother/father]. In order to be eligible for FML, an employee must be employed by the University for at least twelve months and have worked at least 1250 hours during the previous twelve months. In addition, the request for leave must qualify under the FML guidelines.

Eligible employees are entitled to request up to a maximum of twelve (12) weeks of FML leave during each defined twelve-month period for which qualifying criteria have been met.

It has been determined that you meet the eligibility requirements and your request qualifies under FML guidelines. This designated FML is effective [DATE] through [DATE]. You are expected to return to work [DATE] (or your next scheduled work day).

Your current defined twelve-month FMLA period begins on [DATE] and you have [insert hours] FML hours available as of [DATE].

FML leave is unpaid unless you elect to use any accrued, but not taken, sick or vacation benefits. Any paid leave benefits used for your FML leave will count towards the twelve-week entitlement. You have requested to apply [accrued sick/vacation/floating holiday/unpaid] time to this request for leave.

If you are presently covered by payroll deductions in any of the State or University insurance programs, your coverage will continue while you are on your leave of absence. You should contact the campus Benefits Service Center at 312-996-6471 to discuss differences in premium amounts based on your leave type, direct billing of your insurance premiums, and options available to you to “waive” your insurance coverage while on leave of absence.

[insert any of the following statements if appropriate for SURS Disability and/or if leave is due to employee’s own health condition]:

[For questions concerning eligibility for SURS disability benefits, please contact the State Universities Retirement System (SURS) Call Center at 1-800-275-7877, or visit their internet web site at Enclosed is a SURS application packet, should you feel the need to apply for disability benefits.]

[A leave of absence due to an employee’s serious health condition requires a medical clearance to return to work. Please submit medical documentation to [insert department contact information here] from your health care provider indicating clearance to return to work.]

Please do not hesitate to contact me if you have any questions or concerns regarding the information contained in this letter.

Kindest regards,

[HR Department Contact]

cc: [Supervisor]

UIC HR Service Center

File