(DATE)
TO:(EMPLOYEE NAME, JOB TITLE)
(AREA/SHOP OR HOME ADDRESS IF MAILING)
FROM:(DIRECTOR/MANAGER/SUPERVISOR NAME, JOB TITLE)
(DEPARTMENT)
RE:Leave May Be Covered by the Family Medical Leave Act (FMLA)
This letter is to notify you that you may be eligible for leave under the Family and Medical Leave Act (FMLA) beginning XX (INSERT DATE).
In order to determine whether you are eligible for leave under FMLA you must provide medical certification. Please have your health care provider complete the enclosed Family and Medical Leave Certification of Health Care Provider form and return it by XX(INSERT DATE 15 DAYS FROM THIS LETTER). If approved, this leave will be covered by the requirements of the Family and Medical Leave Act (FMLA) and will be counted towards your 12-week entitlement for the 2014 calendar year.
Medical documentation will be kept confidential and separate from your personnel records and should be sent to:
Anne Marie Marshall, HR Specialist
Facilities Services Admin Building, Box 352215
Seattle, WA 98195
Phone: (206) 221-4349, Confidential Fax: (206) 543-5135
If you meet the eligibility requirements under FMLA:
●Employees may be asked to provide medical certification for personal medical leave and/or family medical leave. If a certification is requested, but not provided, approval of the leave request may be denied, rescinded, or the leave may be determined ineligible within the requirements of FMLA.
● Employees may be eligible to use a combination of paid and unpaid leave, consistent with applicable University policies.
● Employees may be asked to present a release to return to work authorization from their medical provider prior to returning to work.
●Employees have the right to return to the same or an equivalent job upon return from approved FMLA leave.
●Employee’s basic health insurance coverage will continue during approved FMLA leave. Employees are responsible for paying their portion of the benefits costs.
●Employees are expected to adhere to the applicable attendance and reporting policies.
If your leave is approved under FMLA, you will need to use accrued leave first in accordance with the applicable Collective Bargaining Agreement and complete the FMLA Leave Form to designate the leave as FMLA protected. In addition, employees are expected to give at least 30 days notice of the need for leave, where the need for leave is foreseeable.
If you have any questions about University of Washington leave policies or about your rights and responsibilities under the Family and Medical Leave Act, please contact Anne Marie Marshall.
cc:(ASSIST DIR or MGR)Anne Marie MarshallDepartmental File
(MGR or SUPV)
Enclosure: Family and Medical Leave Certification of Health Care Provider form