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

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

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The Non FMLA Medical Leave Designation Form 3-9-16 (City University of New York) form is 1 page long and contains:

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NON-FMLA MEDICAL LEAVE - DESIGNATION NOTICE
OHRM - SpecialMedicalLeave-DesignationNoticeForm - 2015
Empl. ID
Name
To:
The Fitness for Duty Certification must address your ability to perform the functions of your job. Refer to Essential Functions listed in the
Job Description provided by the employer, or as based upon the employee's own description of his/her job.
You will be required to present a 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.
The certification you provided is not complete and sufficient. 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.
Date
Date
Date
Type of Leave
Based on the information you have provided to date, the following breakdown of leaves will be recorded:
End Date
Start Date
Anticipated date of return
Additional information is required to determine if your Application for Non-FMLA Medical Leave can be approved
Fitness for Duty Certification
Information needed to make the certification complete and sufficient:
This form must be signed by the Director of Human Resources or Designee:
Name
Date
Supervisor's Name
C:
End Date
Start Date
Type of Leave
End Date
Start Date
Type of Leave
End Date
Start Date
Type of Leave
End Date
Start Date
Type of Leave
End Date
Start Date
Type of Leave
Leave with Pay ends
Health Coverage ends
COBRA begins, if applicable
Date (s) of Special Leave of Absence Coverage (SLOAC)
From
To
TO BE COMPLETED BY HUMAN RESOURCES
Actual Date of Return
Signature
College
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Non FMLA Medical Leave Designation Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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