FAMILY AND MEDICAL LEAVE ACT (FMLA) OF 1993
(For use by Supervisors Following Employee Request for FMLA)
Employee: __________________________________________ Person #: _______________
FMLA Leave Requested on (month/day/year): ______________________________________
The following are specifics which you re being made aware of related to your request for FMLA:
1. The leave you requested will be treated as follows:
_____ Deducted from your FMLA leave entitlement.
_____ Deducted from your FMLA leave entitlement and from your applicable leave accruals.
_____ Deducted from your applicable leave accruals but will not qualify as FMLA.
2. Medical Certification is: _______ Required _______ Not required
If Medical Certification is required, it must be provided within a reasonable period of time or within 15 calendar days
following the date of this notice. Failure to do so may disqualify you from the use of FMLA.
If Medical Certification is required, you have received the Attending Physician’s and Medical Certification Statement
along with this notice.
3. All applicable paid leave must be utilized in conjunction with the leave requested. You currently have leave
balances in the following:
Vacation ______ Sick Leave ______ Holiday ______ Personal Leave ______ Other ________
4. Should the leave include unpaid time, you will be placed on a leave of absence status. In order to maintain your
insurance coverages, you may have to pay premiums monthly. Premiums will be billed by the Benefits Office
and will be due the last day of the month for that month’s coverage. You will be allowed a 30-day grace period
from the due date to remit payment. If payment is not made within the 30-day grave period, you will receive a
final written notice allowing an additional 15 days to remit payment. Failure to pay your premiums will then