EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER
 THE FAMILY AND MEDICAL LEAVE ACT

EMPLOYEE ENTITLEMENT
An eligible employee may take up to twelve weeks (26 weeks to care for a covered servicemember with a serious injury or illness under (e) below) of Family and Medical Leave during each consecutive 12-month period for which eligibility criteria have been met.  The initial 12-month period is measured forward from the date the employee first takes FMLA leave. The next 12-month period begins the first time FMLA leave is taken after completion of any previous 12-month period.  Family and Medical Leave shall be granted for (a) the birth or placement of a child for adoption or foster care; (b) for the care of a son, daughter, spouse, or parent with a serious health condition; (c) when an employee is unable to perform the functions of his or her position due to a serious health condition; (d) because of a qualifying exigency arising out of the fact that a family member (child, spouse, or parent) is on a covered active duty or call to active duty status in support of a contingency operation as a member of the National Guard, Reserves, or Regular Armed Forces; or (e) for the care of a son, daughter, spouse, parent, or next of kin who is a covered servicemember with a serious injury or illness. For leave taken for the birth or placement of a child for adoption or foster care, entitlement expires at the end of the twelve-month period following the date of the birth or adoption placement.

EMPLOYEE ELIGIBILITY
To be eligible for FMLA benefits, a University of Illinois employee must:
	(1)	have worked for the University of Illinois for at least twelve months;
		and
	(2)	have worked at least 1250 hours of service during the previous twelve months.

Definition of a Serious Health Condition and other provisions within the FMLA policy can be found at https://www.hr.uillinois.edu/cms/One.aspx?portalId=4292&pageId=5639.   

APPLICATION PROCEDURES
Employees should complete the TO BE COMPLETED BY EMPLOYEE portion of the FMLA Leave Form and submit it to their supervisor or applicable human resources (HR) office. The supervisor/department designee or HR office completes the TO BE COMPLETED BY DEPARTMENT portion and returns to the employee. A copy should be retained in the department separate from the employee’s personnel file. DO NOT SEND A COPY TO THE HUMAN RESOURCES OFFICE except under the following circumstances:

•	UIUC Academic Professionals (AP) and Faculty must receive approval for unpaid FMLA leaves. Forms should be submitted to the Academic Human Resources office.
•	System Office employees should submit the completed FMLA application and Medical Certification (if applicable) to System Human Resource Services. System HR completes the TO BE COMPLETED BY DEPARTMENT portion.
•	UI Hospital and Clinics (UI Health) employees should submit the completed FMLA application and Medical Certification (if applicable) to UI Health HR. A member of the Absence Management Team completes the TO BE COMPLETED BY DEPARTMENT portion and responds to the request.
•	UIC College of Medicine employees at the Rockford and Peoria campuses should submit the completed FMLA application and medical certification forms to their respective Human Resources offices in Rockford and Peoria; HR will complete the To Be Completed By Department portion.
•	UIS employees must receive approval from the appropriate supervisor or department designee.  Approved forms should be submitted to the Office of Human Resources, HRB-30.  

MEDICAL CERTIFICATION
Certification issued by the employee's or the family member's health care provider is required to support a request for Family and Medical Leave due to a serious health condition (see Medical Certification forms). Requests for paid leaves shall be in accordance with the University's sick leave/vacation policies. Departments may require employees to provide the opinion of a second health care provider designated or approved by the University, but not employed by the University. The opinion of a third provider may be required when there are differing opinions. The opinion of the third provider shall be considered final and shall be binding on the University and employee. Any expenses associated with obtaining second and third opinions shall be the responsibility of the employing department.

CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE
Certification issued by the employee is required for an employee seeking FMLA leave due to a qualifying exigency.  A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a covered military member’s active duty or call to active duty status in support of a contingency operation.

RETURN FROM FAMILY AND MEDICAL LEAVE
The department or applicable HR office may require an employee to obtain a statement from a health care provider that he/she is able to resume work. Employees are expected to contact employing departments at least thirty calendar days in advance of the anticipated date of return. A staff employee who has been absent for Family and Medical Leave shall be restored to the position of employment held by the employee when the leave commenced; or an equivalent position with equivalent employment benefits, pay, and other terms and conditions of employment.

USE OF PAID AND UNPAID LEAVE
Birth or Placement of a Child for Adoption or Foster Care:  Employees have the option to take FMLA leave with or without pay.  An employee may request to apply accrued vacation and/or sick leave during the FMLA period in accordance with Policy and Rules for Civil Service Staff or with university Academic policies. Any portion of the FMLA period for which accrued leave is not applied shall be without pay.

Serious Health Condition, Family Member, Employee, or Covered Servicemember:  Employees have the option to take the leave with or without pay.  For care of a spouse, child, or parent with a serious health condition or because of an employee’s own serious health condition, the leave is provided under the University Sick Leave policy (Policy 10, Sick Leave) and the university Academic sick leave policies.  If an employee’s sick leave is exhausted, the employee may elect to use accrued vacation leave to continue in pay status during the FMLA period.  Sick and vacation leave used for this purpose will be counted towards the FMLA entitlement.

Exigency Leave: Employees have the option to take the leave with or without pay.  An employee may request to apply accrued vacation leave during the FMLA period in accordance with Policy and Rules for Civil Service Staff or with university Academic policies. Any portion of the FMLA period for which accrued leave is not applied shall be without pay.

In addition, employees with a serious health condition, who exhaust their accrued sick leave balances, may be eligible to receive disability benefits through SURS. Employees may request an APPLICATION FOR DISABILITY BENEFITS from the university HR office.  Any portion of the FMLA period for which accrued vacation, sick leave, or disability benefits are not applied shall be without pay.

INSURANCE COVERAGE AND RETIREMENT CONTRIBUTIONS DURING UNPAID LEAVE
Coverage of group health and dental insurance shall be continued by the University at the same level that coverage would have been provided if the employee had remained in continuous employment. Employees are responsible for paying the employee-paid portion of any insurance premiums presently paid by payroll deduction. If the employee does not make required payments during the leave period, the CMS-Group Insurance Division (GID) will terminate the member’s coverage the first day of the current month. These members are ineligible to continue coverage under COBRA and will not receive a COBRA notification letter (eligible or ineligible). CMS will take action to collect all outstanding premium(s), which may include involuntary withholding. Employees are encouraged to contact the Benefits Service Center for information on changes in status and to arrange for billing prior to their last day of work.
Employees pay the entire premium plus a 2% administrative fee for COBRA coverage. Central Management Services (CMS) mails monthly billing statements to the employee's home address on or about the tenth of each month. Bills for the current month are due by the twenty-fifth of that month and are paid to CMS. Individuals electing COBRA coverage have 45 days from the date coverage is elected to pay currently due premiums. Failure to submit payment by the due date terminates COBRA rights.
The University may recover any premiums paid for maintaining coverage for the employee if the employee fails to return from Family and Medical Leave for a reason other than continuation, recurrence, onset of a serious health condition (employee or family), or other circumstances beyond the control of the employee.  Certification of such conditions may be required by the University.

To determine the effect of Family and Medical Leave on the accumulation of service time for retirement and to assure continuation of contributions, the employee should contact SURS at 1-800-ASK-SURS.

QUESTIONS
Employees should discuss questions or disagreements about leave under the Family and Medical Leave Act with their immediate supervisors.  If concerns are not resolved at the supervisory level, the unit head should review the issues.  If the unit head is unable to resolve the issue, the dean or director should be consulted.  Should questions remain, the university human resources office will provide assistance to both the employee and the unit.

Interpretation of specific requirements of the Family and Medical Leave Act policy is subject to provisions contained in the full text of the Act.  Questions regarding the provisions of the FMLA and the Department of Labor Regulations for its implementation should be directed to the campus human resources office.

NOTE: System Office employees should contact System HR if there are questions or disagreements about leave under FMLA.

Urbana-Champaign
•	Staff Human Resources (217) 333-3105 
•	Academic Human Resources (217) 333-6747 

Chicago
•	Faculty Affairs Human Resources (312) 355-2412; fahr@uic.edu
•	HR, Academic Professionals and Civil Service 
o	UI Hospital and Clinics (UI Health) uihloa@uic.edu or fax (312) 355-1548
o	UIC College of Medicine at Peoria (309) 671-8518
o	UIC College of Medicine at Rockford (815) 395-5862
o	All Other Colleges/Units – Labor and Employee Relations (312) 355-3055

Springfield
•	Human Resources (217) 206-6652

System Office
•	System Human Resource Services (217) 333-2600; erhr@uillinois.edu 

UNIVERSITY OF ILLINOIS 
FAMILY AND MEDICAL LEAVE FORM

Effective August 5, 1993, the University of Illinois implemented the Family and Medical Leave Policy in compliance with the federal Family and Medical Leave Act (FMLA) of 1993 and amended the policy in 2013 due to regulation revisions effective March 8, 2013. Such leaves shall be granted to eligible employees (a) for the birth or adoption of a child; (b) for the care of a son, daughter, spouse, or parent who has a serious health condition; (c) when an employee is unable to perform the function of his or her position due to a serious health condition; (d) because of a qualifying exigency arising out of the fact that a family member (child, spouse, or parent) is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard, Reserves, or Regular Armed Forces; or (e) for the care of a son, daughter, spouse, parent, or next of kin who is a covered servicemember with a serious injury or illness. FMLA leaves are granted by the department/unit or applicable human resources office. Eligible employees are entitled to up to twelve workweeks (26 weeks to care for a covered servicemember with a serious injury or illness) of unpaid family and medical leave during each consecutive twelve-month period for which eligibility criteria have been met.  Employees may substitute accrued sick leave and vacation leave for unpaid FMLA.  The initial 12-month period is measured forward from the date the employee first takes FMLA leave. The next 12-month period begins the first time FMLA leave is taken after completion of any previous 12-month period. If foreseeable, requests for Family and Medical Leave should be made at least thirty days in advance of the leave or as soon as practicable. If the need for leave is not foreseeable, requests should be made within two business days of learning of the need for leave.

to be completed by employee	

Employee Name:  _____________________________________	UIN:  ___________________________

Dept./Unit:  __________________________________________	Office Phone:  ____________________

Title:  _______________________________________________________________________________

Supervisor’s Name:  ____________________________________________________________________
	
reason for leave	

______  Serious illness of employee*

______  Serious illness of spouse, child or parent*

	  Name of individual:  _________________________  Relationship:  _____________________

______  Birth of a child

______  Placement of a child with employee for adoption or foster care (attach legal confirmation)

Anticipated date of delivery, adoption or placement:  _______________________________  

______  Qualifying exigency for spouse, child, or parent on covered active duty or call to active duty**

	  Name of individual:  _________________________  Relationship:  _____________________

______  Serious illness or injury of a covered servicemember (spouse, child, parent, or next of kin)*

	  Name of individual:  _________________________  Relationship:  _____________________
*Medical Certification is required.
**Certification of Qualifying Exigency for Military Family Leave is required.	
request to use benefits	
if no amounts are entered, the leave will be unpaid (Mark all that apply)

______  Apply all vacation leave    OR     ______ hours/days of vacation to this leave
______  Apply all sick leave           OR     ______ hours/days of sick leave to this leave
______  Apply parental leave                     ______ Apply as unpaid leave
______  Apply floating holidays                ______ Apply shared benefits, if applicable
______  Other: __________________________________________________________
	 	
expected duration	
leave will be taken as (check one):

______  a block of time from  _______________ to _______________
			           (month/day/year)              (month/day/year)
______ intermittently (e.g., separate blocks of time or any part of a single day due to a single qualifying reason) (please describe on separate sheet and attach to application)

______  temporarily reduced work schedule (please describe on separate sheet)

I have read the “Employee Rights and Obligations Under FMLA” attached and understand all my rights and obligations under this policy. I also understand that any leave taken as designated FMLA leave (paid and/or unpaid) counts toward my FMLA leave entitlement.

_____________________________________________             _____________
Employee Signature						 Date
	
to be completed by department, System HR (for System Office employees), or
Hospital Leave Coordinator (for UI Hospital and Clinics)
{see employee rights and responsibilities}	

1.   Has the employee worked for the employer for at least 12 months?                           Yes        No
      (If no, the employee is not eligible for FMLA.)

2.   Has the employee worked 1250 hours (64% appointment/37.5 hour workweek;        Yes        No
      60% appointment/40 hour workweek) during the previous 12 months? (If no, the 
employee is not eligible for FMLA.)

3a.  Is the reason for the leave because of the employee’s serious health condition?        Yes        No

3b.  Is the reason for the leave because of the employee’s parent, child, or spouse’s 
	serious health condition?                                                                                              Yes        No

3c.  Is the reason for the leave because of the birth, adoption, or placement
      of foster care of a child by the employee?                                                                    Yes        No 

3d.  Is the reason for the leave because of a qualifying exigency arising out of the
	fact that a family member (child, spouse, or parent) is on covered active duty or call to
	active duty status in support of a contingency operation as a member of the
	National Guard, Reserves, or Regular Armed Forces?  				  Yes        No  

3e.  Is the reason for the leave because of the serious injury or illness of a covered
	servicemember?								  Yes       No                                                                                    

4.   Does the employee’s medical certification (which is required for employee’s
	own or family member’s serious health condition, including the serious injury
	or illness of a covered servicemember) support the request for leave?        	 Yes        No

5.  	If requesting qualifying exigency leave for spouse, child, or parent on covered active
	duty or call to active duty, has the appropriate documentation been provided to
	support the request for leave?							 Yes        No

5.   The employee has _______ number of weeks/hours of FMLA leave entitlement 
             remaining at the time of this leave request.

     6.    The remaining FMLA hours will be shared with other active FMLA events.            Yes        No

Based on the answers above, is the employee eligible for FMLA?                         Yes      No                                           
If no, state reason. _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

The department acknowledges that benefits will be applied as shown on the first page of this form:

______  vacation leave hrs    ______  sick leave hrs    ______  parental leave hrs    ______  unpaid hrs  
______  vacation leave days  ______  sick leave days ______  parental leave days  ______  unpaid days
______  floating holidays        ______ shared benefits
______  other: _______________________________________________________________________

Please sign below to indicate your review of this FMLA request.

_____________________________________________		___________________________
Authorized Signature (Department, Unit, System HR, UI Hospital Leave Coordinator)		 Date

If the department believes that the employee is not eligible for FMLA, please consult your central/campus Human Resources office before denying the leave.  You may also contact HR if you have additional questions.

The department is responsible for tracking FMLA usage on an FMLA Usage Form available at http://nessie.uihr.uillinois.edu/pdf/leave/FMLA-VESSA_Usage_rpt.xls