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v ( * + 0 , ( 2 P < 2 d) d) 8 2 ) < * * , 2 V _ : EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER
THE FAMILY AND MEDICAL LEAVE ACT (FMLA)
EMPLOYEE ELIGIBILITY
Employees are eligible for Family Medical Leave (FML) if they have been employed by the University for at least 12 months and worked a minimum of 1,250 hours during the 12 months preceding the leave and if there are at least 50 employees within 75 miles. An employee is entitled to FML once every 12 months and is calculated forward from the date the employee first takes FML. Employees need to apply for FML even if they have accumulated sick/vacation days to cover the absence.
An employee may take up to twelve weeks of FML in a consecutive 12-month period or 26 weeks to care for a covered service member with a serious injury or illness if all eligibility criteria are met. FML is granted for the following reasons:
Birth or placement of a child for adoption or foster care;
To care for an immediate family member (child, spouse, or parent) with a serious health condition;
When an employee is unable to perform the functions of his or her position due to a serious health condition;
Because of a qualifying exigency when a family member (child, spouse, or parent) is on active duty or called to active duty status in support of a contingency operation as a member of the National Guard or Reserves;
To care for an immediate family member (child, spouse, parent, or next of kin) who is a covered service member with a serious injury or illness.
For leave taken for the birth or placement of a child for adoption or foster care. (FML expires at the end of the twelve-month period following the date of the birth or adoption placement.)
If the FML request is for the employees own illness, all available sick leave must be used prior to leave without pay; vacation may be used at the employees discretion. If the FML request is for one of the approved family members, all vacation must be used prior to leave without pay. Paid sick leave used to care for an immediate family member will be determined by University policy or the applicable collective bargaining agreement. The employees health, dental, vision and life insurance will remain in effect during the approved 12-week FML period and premiums will continue to be deducted from his/her check. Should the employee exhaust paid time and be removed from the payroll, Central Management Services (CMS) will bill the employee for the premium during the approved 12-week period. During FML, the employee is responsible for timely payment of the employee's portion of any insurance premiums or it may be cancelled.
FORESEEABLE AND UNFORESEEABLE LEAVE
If the leave is foreseeable, the employee must notify the supervisor of the need for leave at least 30 days before the date leave is to begin. If the employee fails to provide the 30-day notice, FML may not be approved until 30 days have elapsed after the date of the employees notice. Some possible examples of foreseeable leave are for the birth of a child and elective surgery.
When a leave is unforeseeable, the employee is required to provide the supervisor with notice of the need for leave as soon as practicable. This means, generally, that notice is provided within one or two business days of needed leave time. The timing of the notice is dependent upon the nature of the circumstances. Examples of unforeseeable leave could be when circumstances have changed regarding planned leave or due to a medical emergency.
APPLICATION PROCEDURES
Employees should complete the FM Leave Form and submit it to their supervisor.
The supervisor or department designee reviews and signs the form and returns the original to the employee.
A copy should be retained in the department.
The employee mails or delivers the original document to the Office of Human Resources, Rendleman Bldg., Room 3210, Campus Box 1040, Edwardsville, IL, 62026-1040.
MEDICAL CERTIFICATION
A Certification issued and sent to the Office of Human Resources by the employee's or the family member's health care provider is required to support a request for FML due to a foreseeable leave for a serious health condition. If you do not provide the completed Certification 15 calendar days after the employers request, the leave could be denied, your pay could be docked or you could be placed on leave without pay.
CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE
Certification issued by the employee is required for an employee seeking FML due to a qualifying exigency. Complete and sufficient certifications to support a request for FML leave due to a qualifying exigency includes written documentation confirming a covered military members active duty or call to active duty status in support of a contingency operation.
RETURN FROM FAMILY AND MEDICAL LEAVE
If the FML is granted, it is upon the condition that the employee will return to work at its expiration. Failure to return on that date shall be deemed an unauthorized and unexcused absence and is subject to the University Disciplinary Process. The Office of Human Resources requires a statement from a health care provider before an employee is able to resume work. Employees are expected to notify the Office of Human Resources and the employing department at least thirty calendar days in advance of the anticipated date of return if possible. An employee who has been absent for FML shall be restored to the position of employment held 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 FML with or without pay. An employee may request to apply accrued vacation and/or sick leave during the FML period. Any portion of the FML period for which accrued leave is not applied shall be without pay.
Serious Health Condition, Family Member or Employee: 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 employees own serious health condition, the leave is subject to University sick leave policies. If an employees sick leave is exhausted, the employee may elect to use accrued vacation leave to continue in pay status during the FML period. Sick and vacation leave used for this purpose will be counted towards the FML entitlement. 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 Office of Human Resources. Any portion of the FML 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 the employee-paid portion of any insurance premiums previously paid through payroll deduction. If the employee does not make the required payments during the leave period, the CMS-Group Insurance Division (GID) will terminate the members coverage. To determine the effect of FML on the accumulation of service time for retirement and to assure continuation of contributions, the employee should contact SURS at 1-800-ASK-SURS.
Office of Human Resources Benefits Division
Campus Box 1040, Edwardsville, IL 62026-1040
Phone: (618) 6 5 0 - 2 1 9 0 F a x : ( 6 1 8 ) 6 5 0 - 2 6 9 6 E m a i l : h r b e n e f i t s @ s i u e . e d u
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = E m p l o y e e L a s t N a m e : F O R M T E X T F i r s t N a m e : F O R M T E X T S o c i a l S e c u r i t y N u m b e r : F O R M T E X T B a n n e r I D : F O R M T E X T S I U E D e p t : F O R M T E X T S u p e r v i s o r : F O R M T E X T D e p t P h o n e : F O R M T E X T S u p e r v i s o r E m a i l : F O R M T E X T J o b C l a s s i f i c a t i o n : F O R M C H E C K B O X F a c u l t y F O R M C H E C K B O X A d m i n S t a f f (Non-Represented)
FORMCHECKBOX Civil Service FORMCHECKBOX Prof Staff (Represented) LTD insurance? FORMCHECKBOX Yes FORMCHECKBOX NoREASON FOR LEAVE FORMCHECKBOX Serious illness of employee * FORMCHECKBOX Serious illness of employees spouse, child or parent * Name of individual: FORMTEXT R e l a t i o n s h i p : F O R M T E X T F O R M C H E C K B O X B i r t h o f a c h i l d F O R M C H E C K B O X P l a c e m e n t o f a c h i l d w i t h e m p l o y e e f o r a d o p t i o n o r f o s t e r c a r e ( a t t a c h l e g a l d o c u m e n t a t i o n )
A n t i c i p a t e d d a t e o f d e l i v e r y , a d o p t i o n o r p l a c e m e n t : F O R M T E X T F O R M C H E C K B O X Q u a l i f y i n g e x i g e n c y f o r s p o u s e , c h i l d , o r p a r e n t o n a c t i v e d u t y o r c a l l t o a c t i v e d u t y * * N a m e o f i n d i v i d u a l : F O R M T E X T R e l a t i o n s h i p : F O R M T E X T F O R M C H E C K B O X S e r i o u s i l l n e s s o r i n j u r y o f a c o v e r e d s e r v i c e m e m b e r ( s p o u s e , c h i l d , p a r e n t , o r n e x t o f k i n ) * N a m e o f i n d i v i d u a l : F O R M T E X T R e l a t i o n s h i p : F O R M T E X T * M e d i c a l C e r t i f i c a t i o n i s r e q u i r e d . * * C e r t i f i c a t i o n o f Q u a l i f y i n g E x i g e n c y f o r M i l i t a r y F a m i l y L e a v e i s r e q u i r e d . R E Q U E S T U S E O F : ( I F N O A M O U N T S A R E E N T E R E D , T H E L E A V E W I L L B E U N P A I D ( M A R K A L L T H A T A P P L Y ) F O R M C H E C K B O X A p p l y a l l v a c a t i o n l e a v e O R F O R M T E X T h o u r s / d a y s o f v a c a t i o n t o t h i s l e a v e
F O R M C H E C K B O X A p p l y a l l s i c k l e a v e O R F O R M T E X T h o u r s / d a y s o f s i c k l e a v e t o t h i s l e a v e
F O R M C H E C K B O X A p p l y e x t e n d e d s i c k l e a v e
F O R M C H E C K B O X A p p l y a s u n p a i d l e a v e
F O R M C H E C K B O X O t h e r : F O R M T E X T N o t e : W o r k e r s C o m p e n s a t i o n a b s e n c e i s n o t e l i g i b l e f o r E x t e n d e d S i c k L e a v e . C O M P L E T E I F L E A V E I S F O R F A M I L Y M E M B E R : N a m e o f F a m i l y M e m b e r : F O R M T E X T R e l a t i o n s h i p t o E m p l o y e e : F O R M T E X T C a r e t o b e p r o v i d e d : F O R M T E X T C a r e n e e d e d u n t i l : F O R M T E X T I f c a r e i s t o b e p r o v i d e d i n t e r m i t t e n t l y o r y o u n e e d t o w o r k l e s s t h a n a f u l l w o r k s c h e d u l e , p l e a s e i n c l u d e t h e d a t e s a n d t i m e s n e e d e d w i t h t h i s a p p l i c a t i o n . E X P E C T E D D U R A T I O N L E A V E W I L L B E T A K E N F R O M : F O R M T E X T t o : F O R M T E X T
I h a v e r e a d t h e a t t a c h e d E m p l o y e e R i g h t s a n d R e s p o n s i b i l i t ies Under FMLA and understand all my entitlements and obligations under this policy. I also understand that any leave taken as designated FML (paid and/or unpaid) applies toward my FML entitlement. ___________________________________________________ __________________________________
Employees Signature Date
___________________________________________________ ___________________________________ Supervi M T U V k 1 2 L
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I understand the options that are available to me, and I elect the following:
FORMCHECKBOX a. Payout of vacation through 60th day; retain balance, if any.
FORMCHECKBOX b. Payout of all vacation (even if beyond 60th day).
FORMCHECKBOX c. Receive no vacation pay; retain balance until return to work or expiration of benefits.
FORMCHECKBOX d. Employee is not eligible for vacation.
Note: Retain e d v a c a t i o n h o u r s ( i f a n y ) w i l l b e a v a i l a b l e f o r u s e u p o n r e t u r n t o w o r k O R w i l l b e p a i d o n l y u p o n e x p i r a t i o n o f S U R S d i s a b i l i t y b e n e f i t s . B a l a n c e w i l l b e p a i d a t t h e r a t e o f p a y i n e f f e c t w h e n t h e l e a v e b e g a n .
L a s t D a y W o r k e d : F O R M T E X T
I u n d e r s t a n d t h a t i f I c h o o s e o p t i o n a o r c a n d r e c e i v e l u m p a s u m p a y m e n t f o r r e t a i n e d v a c a t i o n a t t h e e n d o f m y l e a v e ( r e s i g n a t i o n o r r e t i r e m e n t ) , I m u s t r e p a y t h e r e t i r e m e n t s y s t e m f o r a n y d i s a b i l i t y b e n e f i t s r e c e i v e d d u r i n g t h e t i m e I c o u l d h a v e u sed that vacation.
___________________________________________________________________ Employees Signature Date
original: Human Resources cc: Department
Additional Information:
SURS disability benefits (50% pay), if approved, are payable beginning the 61st calendar day of disability. All sick leave must be used prior to payment of disability benefits. If your sick leave ends before 60 days, this option allows you to use vacation to stay in pay status through the 60th day. If you do not eventually return to active status, any vacation you retain will be paid upon termination or retirement at the rate of pay in affect when the leave began. In that case, you will be required to repay any disability benefits received during the period that vacation could have been used. This option may be best if your disability is not expected to be permanent.
b. Use this option if you want to use all accrued vacation. This option may be best if you have minimal sick leave. Use of vacation may keep you on the payroll at 100% pay as long as possible. It may also be a good option if your disability is expected to be permanent so that you do not have to reimburse SURS upon termination or retirement.
c. Under this option, you will be pa Z [ \ ] I m m m m dh $If ]gd k $If ]gd k ]gdI+a h kd6 $$If l % &
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