Fillable FMLA Notice Of Eligibility Rights Responsibilities 3-9-16 (City University of New York)

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FMLA Notice Of Eligibility Rights Responsibilities 3-9-16 (City University of New York)

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Eligible employees are entitled to up to 12 weeks of unpaid job-protected leave for certain family and medical reasons within the
calendar period, September 1 - August 31.
- To be eligible, an employee must have worked for CUNY for at least 12 months and have worked at least 1, 250 hours in the 12
months preceding the leave.
- The notice of eligibility must be provided within 5 business days of the employee notifying CUNY of the need for FMLA leave.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
Notice of Eligibility and Rights and Responsibilities
OHRM - FMLA Notice of Eligibility & Rights & Responsibilities -2015 (Page 1)
Empl. ID
Name
PART A: NOTICE OF ELIGIBILITY
you informed us that you were requesting leave for
Your own serious health condition
Birth of a child; to care for your newborn child
Placement of child with you for adoption or foster care
To care for your family member with serious health condition
Because you are the family member/next of kin* of a current
servicemember/veteran with a serious injury or illness
(* check below)
This notice is to inform you that you are (only one reason must be checked)
Eligible for FMLA Leave (See Part B for Rights and Responsibilities)
Not eligible for FMLA leave because
Requested Begin Date
You have not met the FMLA's12-month service requirement.
As of the first date of requested leave, you will have worked approximately
You have not met the FMLA's 1, 250 hours of service requirement.
PART B: RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE
You meet the eligibility requirements for taking FMLA leave and still have FMLA leave available
in the applicable 12-month period. However, in order to determine whether your absence
qualifies as FMLA leave, you must return the following information to us by this date:
If additional certification is requested, CUNY gives you at least 15 calendar days from receipt of this notice to return the forms.
Additional time may be required in some circumstances. If sufficient information is not provided in a timely manner, your leave may be
denied.
The Certification of Healthcare Provider form
Certification of Family Relationship Form
No additional information is requested
To:
On Date
Date
From:
Name
Spouse
Child
Parent
Parent
Child
Spouse
Next of kin
Name /Tel. #
or view the FMLA poster
located in Human Resources.
towards this requirement.
Certification of Family Relationship Form is NOT complete. Please submit by date noted above
For questions, please contact
Other information needed
Provide the following:
The Certification of Healthcare Provider form is NOT complete. Please submit by date noted above
FMLA FORM - 2
College
OHRM - FMLA Notice of Eligibility & Rights & Responsibilities -2015 (Page 2)
FAMILY AND MEDICAL LEAVE ACT (FMLA)
Notice of Eligibility and Rights and Responsibilities
If your leave qualifies as FMLA leave, you will have the following responsibilities while on FMLA leave (only checked items apply)
Make arrangements to continue to make your share of the premium payments on your health insurance to maintain health benefits while
you are on leave. You have a minimum 30-days (or indicate longer period, if applicable) grace period in which to make premium
payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify you in writing at least 15 days
before the date that your health coverage will lapse, or, at our option, we may pay your share of the premiums during FMLA leave, and
recover these payments from you upon your return to work.
You will be required to use your available paid sick, annual, and/or other leave* during your FMLA absence. This means that you will
receive your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave entitlement.
* Available Sick Leave
* Available Annual Leave
* Available Other Leave
While on leave, you will be required to furnish us with periodic reports of your status and
intent to return to work (should be appropriate for the particular leave situation)
Periodic report time
If the circumstances of your leave change and you are able to return to work earlier than the date indicated Page 1 of this Form, you will be
required to notify us at least 2 work days prior to the date you intend to report for work.
If your leave qualifies as FMLA leave, you will have the following rights while on FMLA leave:
1. You have a right under the FMLA for up to 12 weeks of unpaid leave in a fixed leave year from September 1 through August 31.
2. You have a right under the FMLA for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered
service member or veteran with a serious injury or illness. This single 12-month period commenced on this date
3. Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work.
4. You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your
return from FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not have return rights under
FMLA).
5. If you do not return to work following FMLA leave for a reason other than:
1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave;
2) the continuation, recurrence, or onset of a covered service member's serious injury or illness which would entitle you to FMLA leave, or
3) other circumstances beyond your control, you may be required to reimburse CUNY for our share of health insurance premiums paid on
your behalf during your FMLA leave.
6. If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA leave entitlement, you have the
right to have the following sick, annual, and/or other leave* run concurrently with your unpaid leave entitlement, provided you meet any
applicable requirements of the leave policy. Applicable conditions related to the substitution of paid leave are referenced or set forth below.
If you do not meet the requirements for taking paid leave, you remain entitled to take unpaid FMLA leave. (* check applicable)
Contact
Phone Number
* Sick leave
* Annual leave
* Other leave
Name / Telephone #
If you have any questions, please contact
Once we obtain the information from you as specified on this form, we will inform you, within 5 business days, whether your leave will
be designated as FMLA leave and count towards your FMLA leave entitlement.
Conditions applicable to sick/annual/other leave usage are available
on the CUNY website (OHRM-Benefits)
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FMLA Notice Of Eligibility Rights Responsibilities 3-9-16 (City University of New York)

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Completed 18 December 2020

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