UniversityofHouston

FMLA/Parental Leave Application

Name: Empl ID:
Employee’sEmailAddress:* Telephone#
HomeAddress:StateZip
Department:Campus:
SupervisorNameTelephone#
Pay Type:Monthly Biweekly
Normalmonthsworkedper year: 12 months 9monthsOther
Requestfor: FamilyandMedicalLeave -or- ParentalLeave
*Allcommunications fromHR regarding your FMLwillbemadeviathisEmailaddress
Isthisajointapplicationwith aspousewhois alsoaUHemployee?Yes NoIsthe qualifyingconditiondue tothe birthorplacementofachildwithyouforadoptionorfostercare?Yes NoPleaseindicate:□ Birth -or- □ Adoption -or- □FosterCareAnticipatedbirth/placementdate:
Isthequalifyingeventdueto MilitaryLeave:ActiveDuty LeaveMilitary caregiverleave? Yes NoActiveduty:Qualifyingexigency Relationship: ActivedutyPaidVacation? Yes No
Military caregiver: Certification ofhealth careprovider: Yes No Certificationfornextofkin? Yes NoIs thequalifyingconditionduetotheserioushealthconditionofachild,parent,or spouseoftheemployee? Yes NoIfleaveisrequestedfora serioushealthconditionofa dependent,pleaseprovidethefollowinginformation:
Name:Relationship: DOB (ifchild)
Isthequalifyingconditionduetotheserioushealthconditionoftheemployee?Yes NoDateofeventoronsetofcondition: / / Duration: LastDayWorked:/ /
Areyourequestingintermittentleave?YesNo
Ifyes,pleaseprovide: Work/leaveschedule: Durationofleave: NOTE:Recertificationisrequiredevery6monthsforintermittentleave.
Iunderstandandagreetothefollowingprovisions. MdenotesMilitaryLeaveacknowledgement
IcertifythatIhavereceived theHealth CareProviderCertificationandmustreturnitwithin 15calendardaysor myFMLwillbedenied.
I understandIwill begivenstatepremiumsharingtowardthecostofhealth insurancewhileon FML. I will bebilled(ortheamountwill bedeductedfromanysickleaveor vacationpay)foradditionalpremiumsinexcessofthestatepremiumsharing.ShouldIfailto paytheadditionalpremiums, thehealth coveragewill bechangedto theEmployeeOnlylevelandoptionalcoveageswillbeterminated.
MContinuationofgroupinsuranceissubjecttotheconditionsandpoliciesofthe‘EmployeesRetirementSystemofTexas”relatingtocoveageswhileonleavewithoutpay.
MIwillreportperiodicallyduringtheleave(at leastonceperweek)to mysupervisoronmyleavestatusand intentionto returntowork.
  • Imustexhaustallsick,vacation,orotherpaidleaveaccumulationswhiletakingFMLAleave.Oncemypaidleaveisexhausted,Iwillbeplacedonleavewithoutpay.
  • After12weeksortheamountofapprovedleave,ifIdonotreturntoworkorcontactmysupervisorormanageronorbeforethatdateintended, itwillbeconsideredthatIabandonedmyjob.
  • IwillreceivethestatecreditforhealthinsuranceduringtheFamilyorMedicalorParentalleaveandwillbebilledforanyadditionalinsurancepremiumsdue.ShouldIfailtopaytheadditionalpremiums,myhealthinsurancecoveragewillbechangedtoemployeeonlylevelandoptionalcoverageswillbecanceled.ContinuationofgroupinsuranceissubjecttotheconditionsandpoliciesofERSrelatingtocoveragewhileonleavewithout pay.
  • Imustprovidea releaseto return towork frommyphysicianfollowingmy leave.Should Ifailto doso,my departmentmaydenyrestorationofmyemployment.
EmployeeSignature:Date:
Faxthisformto713-743-4830
EmployeeSection
YOURRIGHTS UNDERTHEFAMILYANDMEDICAL LEAVEACT OF 1993

TheFamilyMedicalLeaveAct (FMLA)requirescoveredemployerstoprovideupto12weeks(upto26weeks formilitarycaregiverleave)ofunpaid,job-protectedleaveto“eligible”employeesforcertainfamilyandmedicalreasons.Employeesareeligibleiftheyhaveworkedfor acovered employerfor atleastoneyear, andfor 1,250hoursovertheprevious12months, andifthereareatleast50 employeeswithin75miles.

ADVANCENOTICEANDMEDICALCERTIFICATION

Theemployeemay berequiredtoprovideadvanceleavenoticeandmedicalcertification.FMLAleavewillbedeniediftherequirementsarenotmet.

  • Theemployeemustprovide30days’noticewhentheleaveis“foreseeable”
  • TheUniversityofHoustonrequiresmedicalcertificationtosupportarequest forleavebecauseofaserioushealthcondition,mayrequireasecondorthirdopinion(attheuniversity’sexpense),andrequirescertificationoffitnesstoreturntowork.
JOB BENEFITSANDPROTECTION

ForthedurationofFMLAleave,theUniversityof Houstonmustallowtheemployeetomaintaintheemployee’shealthcoverageunderany“grouphealthplan”.

  • UponreturnfromFMLAleave,most employeesmustberestored totheiroriginalorequivalentpositionswithequivalentpay,benefits,and otheremploymentterms.
  • TheuseofFMLAleavecannotresultinthelossofanyemploymentbenefitthataccruedpriorto thestartofanemployee’sleave.
ENFORCEMENT
  • TheU.S.DepartmentofLaborisauthorizedtoinvestigateandresolvecomplaintsofviolations.
  • Aneligibleemployeemaybringacivilactionagainsttheemployerforviolations.

FMLAdoesnotaffectanyFederalorStatelawprohibitingdiscrimination,orsupersedeanyStateorlocallaworcollective.

ThisSectionToBeCompletedByHumanResources

Employee’sJobTitle:FTE:HireDate: //

VacationBalance:SickLeave Balance:

HRServiceCenterSignature:Date:

NOTE:

  • HRwill reportanychangesintheapproved leaveimmediatelytotheDepartment
  • HRwillprepareanePARto changetheemployee’sstatusfrom activetopaidor unpaidleave.
  • HRmayrequest leaverecords,ifnecessary, forprocessingbenefits,includingbutnotlimitedtodisabilityapplications,workerscompensationclaims,and deathclaims.
Faxthisformto713-743-4830

Revised: February2015

325McEIhinneyHall,Houston,TX77204-5009∙Phone713.743.3988∙Fax713.743.4830

FMLPHYSICIAN’SINFORMATIONRELEASE

TO:

(AttendingPhysician)

RE:

(PrintedNameofPatient)

ThisisanauthorizationtoreleaseallinformationpertainingtomyconditiontotheUniversityofHouston,OfficeofHumanResources.PleasereturntheoriginalwiththeCertificationofHealthCareProviderformandretainacopywithyourrecords.

Iunderstandthatthisauthorizationcanberevokedatanytimebymeinwriting,butitwillnotberetroactiveforinformationpreviouslyreleasedingoodfaith.

PatientSignature:

DateSigned:

YouArethePride.

FMLEmployeeResponsibilities

1.Itis theimmediateresponsibility of theemployee toinformtheirdepartmentsthattheyareapplyingforFMLincludingwhatdates they anticipatebeingoutonFML.

2.BeawaretheFMLprocessisa15day/2.5weekperiodthatwillbedeniedifthecertificationisnotreceived.

3.OnceyouareoutonFML,youmust contactyourdepartment/supervisoratleastonce a weekduringthedurationof yourleave.

4.ProvideanEmail thatyoucheckregularlyas thiswillbethecommunicationmethodforHRwhensendingyouanyFMLnotificationsincludingapprovalordenial.

5.IfyouareonFMLandare inanunpaidstatus,itis yourresponsibilityto payyourpremiums toERS directlyoryouwilllosethosebenefits.

February2015