Fillable FMLA Designation Form 3-9-16 (City University of New York)

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FMLA Designation Form 3-9-16 (City University of New York)

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FAMILY AND MEDICAL LEAVE ACT (FMLA) - DESIGNATION NOTICE
OHRM - FMLA DESIGNATION NOTICE FORM - 2015 Page 1
SEE PAGE 2 FOR MORE INFORMATION
Empl. ID
Name
To:
A list of essential functions of your position/your job description has been provided to you. The "Fitness for Duty" Certification must
address your ability to perform the essential functions of your position.
You will be required to present the "Fitness for Duty" Certification prior to being restored to employment. If such certification is not
received in a timely manner, your return to work may be delayed until such certification is provided.
You will NOT be required to present a "Fitness for Duty" Certification prior to being restored to employment.
You will be required to furnish periodic reports of your status and intent to return to work every 30 days while on leave.
From
To
Your leave will involve
Continuous absence from work
Intermittent absence from work *
Reduced work schedule*
* Per schedule detailed in the FMLA Request Form
If your leave is unscheduled, it will not be possible to provide the days that will be counted against your leave entitlement at this time. You
have the right to request this information once in a 30-day period (if leave was taken in the 30-day period).
You will NOT be required to furnish periodic reports of your status and intent to return to work every 30 days while on leave.
Date
Date
Type of Leave
The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially
unknown. Based on the information you have provided to date, and the current record of your time and leave balance, the following
breakdown of leaves will be recorded.
To
From
Anticipated date of return
Periodic Reports
Fitness for Duty Certification
Your leave request is approved. The following period is designated as FMLA Leave
To
From
Type of Leave
To
From
Type of Leave
To
From
Type of Leave
We are exercising our right to have you obtain a second or third opinion medical certification at our expense & we will provide further
details at a later time.
Submit additional information by
Additional information needed to make the certification complete and sufficient
The certification you provided is not complete and sufficient to determine whether the FMLA applies to your leave request and you
must provide the following information no later than the date specified, unless it is not practicable under the particular circumstances
despite your diligent good faith efforts, or your leave may be denied.
Additional information is required to determine if your FMLA Leave Request can be approved
FMLA FORM - 4
College
If you normally pay a portion of your health insurance, these payments must be made during your leave. If you remain on payroll, your
premium deductions will automatically continue. If any part of your leave is or becomes unpaid, and you normally contribute to your health
plan, information will be sent to you under separate cover outlining the procedures necessary for remitting payments to your health
insurance carrier.
CUNY will continue to provide payment and will deduct your portion, if any, for pension contributions during the paid portion of your leave.
While on unpaid leave, pension contributions will not be made by the University. However, if you are a Tier 1 member of the NYC TRS, any
unpaid FMLA leave may be creditable towards retirement benefits provided other eligibility factors are met. Please contact the College
Benefits Office for details.
OHRM - FMLA DESIGNATION NOTICE FORM - 2015 Page 2
Date
Name
This form must be signed by the Director of Human Resources or Designee
You have exhausted your FMLA Leave entitlement in the applicable 12-month period
The FMLA does not apply to your leave request
Your FMLA Leave is not approved
FAMILY AND MEDICAL LEAVE ACT (FMLA) - DESIGNATION NOTICE
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FMLA Designation Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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