To:	[Employee’s Name], [Employee’s UIN]
[Employee’s Department]
[Employee’s Work Address]
[Employee’s Mail Code]

From:	[Name]
	[Title]  

Date:	[Date]

Re:	Approved University Family Medical Leave

The attached University Family Medical Leave (UFML) form has been reviewed and it has been determined that you are eligible for UFML leave.  Your requested leave (check one of the following)  will begin on or around [date];  will begin on [date];  began on [date].  The time taken for this leave will count toward your UFML entitlement of leave per twelve (12) month period.  You are eligible for UFML leave as follows:

Type of Leave: 

•	Block of Time: [list dates]

•	Intermittent: [describe specific circumstances and dates that apply]

•	Reduced schedule: [list schedule]

Leave Usage:

•	Vacation Leave:  _____ days / _____ hours to be applied

•	Sick Leave:  _____ days / _____ hours to be applied 

•	Unpaid Leave:  _____days / _____ hours to be applied

Please be aware that, while on unpaid leave, you will be billed 100% of your insurance premiums, including the University’s contribution.  Failure to pay these premiums will result in a loss of coverage.  The employer-paid portion may be reimbursed through the University Family Medical Leave Reimbursement Plan.  Specific information about the reimbursement plan, including the reimbursement form, can be found at https://hr.uillinois.edu/PolicyCompliance/Leave/UFMLReimbursement.cfm. 

Sincerely,

(Name)
(Title)

Cc:  Unit Supervisor
	Campus Human Resources Office