Template for employee absences that may qualify as

Family and Medical Leave (FML)

  • The letter should be utilized once the unit/college has received information regarding an employee’s absence that may qualify as FML (i.e. out sick for more than 3 calendar days)
  • The letter shall be issued no later than 5 days after receiving notification of the absence.Once issued, both employee and unit supervisor should receive a copy of the letter and additionally 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 also 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, IL Zip Code]

Dear [employee name]:

[Department Name] was informed that you have been absent since [DATE], and believe your absences may qualify under the Family and Medical Leave Act (FMLA). FMLA entitles administratively and medically eligible employees to a maximum of twelve (12) weeks of unpaid leave each twelve-month period for a covered circumstance.

Effective [DATE], your absences are provisionally designated as block of time FML qualifying leave, pending the receipt of a completed application and medical certification.

You are being requested to complete the enclosed Family and Medical Leave (FML) application and have the treating physician complete the enclosed certification of health care provider form. Please return the completed documents within 15 calendar days of receipt of this letter to [insert department name/contact and contact information].

FML leave is unpaid unless you elect to use any accrued, but not taken, sick or vacation leave benefits. Any paid leave benefits used for your FML leave will count towards the twelve-week entitlement. [insert the following if applicable:]You have not designated benefits usage to our department as of this date.

You will be notified regarding the final determination of your FML eligibility after we have received and reviewed the documentation. The requested information must be submitted within 15 calendar days of receipt of this letter. Failure to return the necessary documentation within the requested timeframe may result in absences being designated as unauthorized and subject you to discipline up to and including discharge for leave taken without authorization.

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 UPB Benefits 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.

Thank you.

Kindest regards,

[HR Leave Coordinator]

cc:[Supervisor]

UIC HR Service Center

File