April 2 2020
Information for Employee on Completion of E-FMLA Leave Request Form
1. Do not use this form unless related to COVID-19 and Emergency Family and Medical Leave Expansion Act (E-FMLA).
For other medical leave requests, use the Medical Leave Request Form (MLR).
2. Falsification of this request, or any documentation provided to support this request, is cause for immediate dismissal.
3. You must complete all fields check all appropriate boxes in Section I.
a. Above Section I, select the appropriate request type. If you are not already approved for a leave of absence for this
reason, select NEW leave of absence. If you have already submitted a request for this reason but the dates or other
information has changed since the original request was submitted, select REVISION. To request an extension of a
current and previously approved leave of absence, select EXTENSION.
b. Please enter the requested personal information in each field.
c. In the REASON section, provide the information requested. The E-FMLA provides this additional reason to qualify
for FMLA but does not provide a separate FMLA bank. The maximum total FMLA entitlement per Fiscal Year is
12 weeks. If you need to provide care for a child older than fourteen (14) during daylight hours, a statement that
special circumstances exist requiring you to provide care may be requested.
d. Select the type of leave: full (or continuous) or reduced work schedule. During a full leave, an employee does not
work for a continuous period. A reduced work schedule leave is when an employee is requesting a change in their
normal scheduled workdays to less than full-time. When requesting a reduced work schedule, the employee must
also attach a proposed work schedule. To work from home, you must submit a completed COVID-19 Emergency
Remote Work Agreement (https://www.ucf.edu/safety/coronavirus/working-remotely/
).
e. Enter your requested leave beginning and ending dates and the date and time you plan to return to a normal work
schedule (generally the day after the leave ends). The Families First Coronavirus Response Act (FFCRA) is
effective 04/01/20 and ends 12/31/20.
f. Check the appropriate box(es) if you want to use Emergency Paid Sick Leave, Emergency Family Medical Leave,
an accrued leave, and/or take leave unpaid. UCF provides up to 80 hours of paid sick leave under the FFCRA. For
this request, it also provides up to an additional 10 weeks leave at two-thirds (⅔) pay when designated FMLA up
to a maximum $200 daily and $10,000 total benefit. Accrued leaves can be used to supplement the FFCRA benefit.
You will need to submit LAPERs to notify your department how you wish to be paid (or not paid) for time off
during the course of your leave.
4. Once Section I is completed, submit the form to your department for the completion of Section II. USPS or A&P
employees submit to your immediate supervisor and Faculty submit to the department chair. Once Section II is
completed, the department forwards to HR Leave Administration.
5. You will receive notification of approval or denial of the requested leave of absence via email. Questions regarding this
form should be directed to HR Leave Administration at 407-823-2771, or you may email questions to them at
loaandworkcomp@ucf.edu
.
6. Once your leave is approved, you may be expected to provide a completed Intent to Return to Work Form by the date
stated in your approval letter. Should you require a leave extension, you must provide an “Extension” COVID-19 Leave
Request Form (CLR). If you are unable to return to work at all, you may also submit your written resignation.
7. You are responsible for payment of your benefits premiums. If, for any reason, the premiums are not deducted from
your paycheck it is your responsibility to immediately contact the HR Benefits Section at 407-823-2771 and make
arrangements to pay for my premiums. Otherwise, your benefits will be suspended and unusable until all back
payment is received and processed.
Information for Departments on Completion of E-FMLA Leave Request Form
1. Your employee will complete Section I and submit to the department for the completion of Section II.
2. This request for leave must have Departmental Acknowledgment Signature by the Chair for Faculty or by the Supervisor
for USPS and A&P.
3. All E-FMLA Leave Request Forms must be completed and forwarded by the department to HR Leave Administration
within 48 hours of receipt to ensure compliance with federally mandated deadlines.
4. The final approval or denial authority for leaves of absence has been delegated to the Chief Human Resources Officer
(or their designated representative).
5. Your employee must submit LAPERs to notify your department how they wish to be paid (or not paid) for time off (see
also 3f above). FMLA tracking should be included if the leave is designated as FMLA protected.
6. An employee on leave to care for a child should submit an Intent to Return Form. The department then submits an
ePAF to return the employee back to active pay status.
7. Questions regarding this form should be directed to HR Leave Administration at 407-823-2771 or you may email
questions to loaandworkcomp@ucf.edu
.
