EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER
 UNIVERSITY FAMILY MEDICAL LEAVE

For the Care of a Registered, Same-Sex Domestic Partner

This application should only be completed for University Family Medical Leave (UFML) to care for a registered, same-sex domestic partner.  UFML may be granted for the following:
•	the care of a registered, same-sex domestic partner with a serious health condition.
•	because of a qualifying exigency arising out of the fact that a registered same-sex domestic partner is a member of the Reserves or the regular Armed Forces and is deployed to a foreign country on covered active duty.
•	the care of a registered same-sex domestic partner who is a covered servicemember with a serious injury or illness.   

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) University Family Medical Leave (UFML) 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 either UFML or Federal FMLA leave. The next 12-month period begins the first time UFML or Federal FMLA leave is taken after completion of any previous 12-month period.  

EMPLOYEE ELIGIBILITY
To be eligible for UFML 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; and
	(3) 	have completed, and submitted to the campus Benefits Service Center, the University Affidavit of Domestic Partnership (https://nessie.uihr.uillinois.edu/pdf/benefits/DPAffidavit.pdf); and
	(4)	have not have previously exhausted their eligibility for leave under UFML or Federal FMLA for the applicable current 12-month period.

SERIOUS HEALTH CONDITION
Serious health condition means an illness, injury, impairment, or physical or mental condition that involves:
•	any period of incapacity or treatment connected with inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical facility;
•	any period of incapacity requiring absence of more than three full consecutive calendar days from work, school, or other regular daily activities that also involves continuing treatment (or under the supervision of) a health care provider;
•	any continuing treatment by (or under the supervision of) a health care provider for a chronic or long-term health condition that is incurable or so serious that, if not treated, would likely result in a period of incapacity of more than three calendar days; or
•	prenatal care; or
•	an injury or illness incurred by a covered servicemember: (a) in the line of duty on covered active duty in the Armed Forces (or existed before the beginning of the member’s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces); and (b) that may render the servicemember medically unfit to perform the duties of the servicemember’s office, grade, rank, or rating.  In the case of a veteran, this injury or illness could have “manifested itself before or after the member became a veteran”.

APPLICATION PROCEDURES
Employees should complete the TO BE COMPLETED BY EMPLOYEE portion of the UFML Application and submit it to their supervisor. The supervisor or department designee 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 UFML leaves. Forms should be submitted to the Academic Human Resources office.
•	System Office employees should submit the completed UFML 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 UFML 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.
Employees who wish to take advantage of this leave must have completed and submitted the University of Illinois Affidavit of Domestic Partnership form prior to completing the University Family Medical Leave application.  This form can be found at https://nessie.uihr.uillinois.edu/pdf/benefits/DPAffidavit.pdf or obtained from the campus Benefits Service Center.

MEDICAL CERTIFICATION
Certification issued by the registered same-sex domestic partner’s health care provider is required to support a request for University Family Medical Leave due to a serious health condition (see appropriate Medical Certification form). 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 UFML leave due to a qualifying exigency.  A complete and sufficient certification to support a request for UFML leave due to a qualifying exigency includes written documentation confirming a covered military member’s covered active duty or call to covered active duty status.

RETURN FROM UNIVERSITY FAMILY MEDICAL LEAVE
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 University Family 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
Employees have the option to take the leave with or without pay.  For care of a registered same-sex domestic partner with a serious health condition, the leave is provided under University policy, including Policy and Rules, Policy 10; General Rules, Section 4; and the campus 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 UFML period.  Sick and vacation leave used for this purpose will be counted towards the UFML entitlement.

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.   Because UFML is a University leave and not a State leave, Central Management Services (CMS) will recognize this leave as a personal leave of absence, not as UFML leave.  Regulations state that, during a period of unpaid personal leave, the employee will be billed both the state monthly contribution as well as the premium that would have been deducted from the employee’s pay had he/she remained on payroll.  Upon request by the employee, the State portion may be reimbursed through the University’s Family Medical Leave Reimbursement Plan.  Specific information about the reimbursement plan can be found at: (insert link). 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 within thirty days following the last day of paid employment to understand their billing obligations and discuss the reimbursement process.  Employees should also contact the Benefits Service Center to determine how optional benefits plans will be affected during a period of unpaid leave.

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 University Family Medical Leave for a reason other than continuation, recurrence, onset of a serious health condition (of the registered same-sex domestic partner), or other circumstances beyond the control of the employee.  Certification of such condition may be required by the University.

To determine the effect of University Family 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 University Family Medical Leave with their immediate supervisor.  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 University Family Medical Leave policy is subject to University provisions.  Questions regarding these provisions should be directed to the university human resources office.

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

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) email  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 APPLICATION FOR
UNIVERSITY FAMILY MEDICAL LEAVE 

For the Care of a Registered, Same-Sex Domestic Partner

University Family Medical Leave shall be granted to eligible employees only for the care of a registered same-sex domestic partner.  Domestic partners are recognized by the University through completion and submission of the University of Illinois Affidavit of Domestic Partnership.

UFML leaves are granted by the department/unit. 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 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 UFML.  The initial 12-month period is measured forward from the date the employee first takes UFML leave. The next 12-month period begins the first time UFML leave is taken after completion of any previous 12-month period. If foreseeable, requests for Family 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 registered, same-sex domestic partner* 
	  Name of individual:  ________________________  
______  Qualifying exigency for registered, same-sex domestic partner on covered active duty or call to covered 	active duty**

	  Name of individual:  _________________________  

______  Serious illness or injury of a covered servicemember (registered, same-sex domestic partner)*

	  Name of individual:  _________________________  

*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 as unpaid leave
______  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 due to single illness) (please describe on separate sheet)
______ 	temporarily reduced work schedule (please describe on separate sheet)
I have read the attached “Employee Rights and Responsibilities Under University FML” attached and understand all of my rights and obligations under this policy. I also understand that any leave taken as designated UFML leave (paid and/or unpaid) counts toward my UFML leave entitlement.
________________________             ______________________
Employee Signature						 Date
	
to be completed by department, System HR (for System Office employees), or
UI Health HR (for medical center employees)
{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 UFML.)

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 UFML.)

3a. 	Is the reason for the leave due to a serious health condition of the employee’s
      registered same-sex domestic partner?	Yes	No

3b.  Is the reason for the leave because of a qualifying exigency arising out of the
	fact that a registered same-sex domestic partner is on covered active duty or call to
	covered active duty as a member of the
	Reserves or the regular Armed Forces?  	Yes	No  

3c.  Is the reason for the leave because of the serious injury or illness of a covered
	Servicemember (registered same-sex domestic partner)?	Yes       No                                                                                    

4.   Does the medical certification (which is required for registered same-sex domestic
	partner’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 registered same-sex domestic partner on
	covered active duty or call to covered active duty, has the appropriate documentation
	been provided to	support the request for leave?					       Yes	       No

6.	Have the employee and domestic partner completed and submitted the
	University of Illinois Affidavit of Domestic Partnership?  For verification,
	please contact the University Payroll and Benefits: Chicago (312) 996-6470,
	Springfield (217) 206-7142, Urbana (217) 333-3111.	Yes	No

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

Based on the answers above, is the employee eligible for UFML?                     	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    	______  unpaid hrs  
______  vacation leave days  		______  sick leave days 		unpaid days
______  other: _______________________________________________________________________

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

________________________________________________		___________________________
Authorized Signature (Department, Unit, System HR, UI Health HR)                          Date

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

The department is responsible for tracking UFML usage on the FMLA/VESSA/UFML Usage Report available at https://nessie.uihr.uillinois.edu/pdf/leave/fmla_usage.pdf