Fillable Towson University Request for Family and Medical Leave (FMLA)

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Towson University Request for Family and Medical Leave (FMLA)

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The Towson University Request for Family and Medical Leave (FMLA) form is 2 pages long and contains:

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Office of Human Resources
Human Resources Towson University - 8000 York Rd, Towson MD 21252 - 410-704-2162 - towson.edu/hr
August 2019
Request for Family and
Medical Leave (FMLA), Page 1
Upon completion, fax page two of this form to the Office of Human Resources (OHR) – 410-704-6320
Employees seeking leave must complete and submit the following FMLA forms: (1) Request for Family and
Medical Leave; and (2) Certification of Health Care Provider. Medical certification must be provided as follows:
30
calendar days prior to the first day out when the need for leave is foreseeable;
or within 15 calendar days of the first day out when the need for leave is unexpected.
Leave Request and Medical Certification
I agree to provide the university with accurate and timely information related to my request for leave, any
modifications to my request for leave, or changes to the return to work date.
In accordance with the Health Insurance Portability and Accountability Act (HIPAA), all medical certifications are
reviewed solely by the appropriate human resources staff exclusively for the purpose of evaluating the request
for family and medical leave.
I understand leave may be delayed until I provide a completed medical certification form.
I understand the university may require further medical clarification or recertification during the course of the
leave, as deemed appropriate.
I understand requests for intermittent leave, reduced work schedule, and workload modification (faculty only)
are subject to review and consultation with my department and the OHR.
I understand intermittent absences should be scheduled to provide the least amount of disruption to
department operations.
If I am seeking to return to work after leave due to my own serious health condition, I must provide certification of
my fitness to return before I may return to work.
Health Benefits, Retirement Benefits, Leave Accrual, and Timekeeping
Coverage under any group health plan will be maintained for the duration of FMLA leave at the level and under
the conditions coverage would have been provided if I had continued to work.
If the FMLA is paid, premium contributions will continue to be made by the method normally used for payment.
If the FMLA is unpaid, I am responsible for the employee contribution portion of the premium.
If I fail to return from FMLA for a minimum of 30 calendar days, other than instances where returning is beyond
my control due to a serious health condition, the university may recover 100% of the premium the institution paid
for maintaining coverage during any period of unpaid leave.
If I am enrolled in the Maryland State Retirement and Pension System (MSRPS) and any portion of my leave will
be unpaid, I must contact the university Benefits Specialist in advance of my leave. The Benefits Specialist will
consult with me regarding whether the MSRPS considers my leave a qualifying leave of absence. If so, I may be
eligible to receive eligible and creditable service for certain periods of unpaid employer approved leave.
University policy requires me to use accrued leave during the FMLA period. FMLA runs concurrent with paid
leave. I understand I will continue to accrue leave during paid leave periods.
If I am using intermittent FMLA, I will record the appropriate leave code and amount of leave on my time sheet
and indicate in the remarks section - FMLA and the dates in the pay period coincident with FMLA. If I am using
FMLA in a continuous block of time, my supervisor will be advised how to complete my time sheet during my
absence.
If I exhaust my accrued leave before the conclusion of my FMLA, I will use leave code FMLA on my time
sheet, which represents unpaid FMLA.
Ple
ase continue to page two to complete your request for FMLA.
My signature on page two of this form, Request for FMLA, acknowledges receipt and understanding of this information.
Human Resources Towson University - 8000 York Rd, Towson MD 21252 - 410-704-2162 - towson.edu/hr
Towson University – Request for FMLA – Page 2 - Upon completion, fax this page to the OHR-410-704-6320
I acknowledge receipt and understanding of the information contained on page one of this FMLA request form.
Print name/telephone number: Signature/Date:
Employee Information
Name: ID: DOH:
Title: Dept: Supervisor:
FMLA Request Details
☐ Initial ☐ Recertification ☐ New (previous FMLA period expired)
Total FMLA taken within the past 12 months: ☐ N/A Hours_______________ Days_______________
Reason for FMLA
☐ Birth of a child ☐ Child placement-adoption/foster care ☐ Child-care within 12 mos. of birth/adoption
☐ Care for an immediate family member with a serious health condition
Name: Relationship: If child, DOB:
☐ My own serious health condition ☐ Military-due to qualifying exigency ☐ Care for covered service member
Request for Continuous Leave (block of time-days, weeks, months)
Leave commences on: Anticipated return to work date:
Request for Intermittent Leave (periodic time off)-Subject to consultation with department and the OHR
Begin date: End date: Duration: Frequency:
Request for Reduced Work Schedule (fewer hours/day or days/week)-Subject to consultation with dept. and OHR
Begin date: End date: Duration: Schedule requested:
FACULTY ONLY – Workload Modification when FMLA runs concurrent with parental leave
Workload agreement required. Subject to consultation with department and the OHR.
☐ Course release. Provide/attach details:
☐ Spreading teaching responsibilities over terms before and after the parental leave period. Provide/attach details:
☐ Redistribution of duties-substitute teaching assignment with other dept. or academic service. Provide/attach details:
☐ Part-time employment. Provide/attach details:
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Towson University Request for Family and Medical Leave (FMLA)

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Completed 20 December 2019

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