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Your Rights under the Family and Medical Leave (University of Texas Rio Grande Valley)

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Your Rights under the Family and Medical Leave Act [ FMLA ] of 1993
The FMLA requires the University of Texas Rio Grande Valley [UTRGV] to provide up to 12 work weeks of paid or unpaid leave to eligible employees for qualifying
family and medical reasons. Family Medical Leave [FML] coordinates with but is not in addition to other leave [ for example: annual, sick, leave without pay ] that an
employee may use for covered purposes. Employees are eligible if they have worked for UTRGV or another Texas state agency for at least 12 months and have been
employed for 1,250 hours during the previous 12-month period.
Employees with less than twelve months of state service or who have worked less than 1,250 hours in the twelve-month period preceding the start of the leave are
eligible to take a parental leave of absence for the birth of a child or the adoption or foster care placement of a child under the age of three. This entitlement
provides up to 12 weeks [480 hours] of unpaid leave. This entitlement may NOT be combined with the FML entitlement.
REASONS FOR TAKING LEAVE
An eligible employee is entitled to FML for any one, or more, of the following reasons:
The birth of the employee's son or daughter, and to care for the newborn child;
The placement with the employee of a child for adoption or foster care, and to care for the newly placed child.
To care for the employee's spouse, son, daughter, or parent with a serious health condition; and,
Because of a serious health condition that makes the employee unable to perform one or more of the essential functions of his or her job.
Because of military family leave entitlements.
ADVANCE NOTICE
To qua
lify for FML, the employee will be required to provide advance leave notice if the leave is foreseeable.
The employee must provide 30 days advance notice based on an expected birth, placement for adoption or foster care, or planned medical treatment for a
serious health condition of the employee or of a family member.
The employee shall advise the employer as soon as practicable if dates of scheduled leave change, are extended or were initially unknown.
It is expected that the employee will give notice to the employer within no more than one or two working days of learning of the need for leave.
MEDICAL CERTIFICATION
The University requires that an employee provide a certification issued by the health care provider of the employee or the employee's ill family member.
When the leave is foreseeable, medical certification should be provided before the leave begins.
If the leave is not foreseeable, medical certification is to be provided within two business days after the leave commences.
A physician's statement certifying the condition is required and must be furnished within fifteen days after the request for FML is submitted, unless there are
extenuating circumstances. The statement must include the following:
The date on which the condition started;
The probable duration of the condition;
The appropriate medical facts regarding the condition; and
Where applicable, a statement that the employee is needed to care for the child, spouse, or parent, and an estimate of the amount of time that such care is
needed.
When the leave request is for intermittent leave or leave resulting in a reduced work schedule, a statement of the medical necessity for the intermittent leave
and the expected duration is required.
PAID LEAVE
University requires that an employee utilize vacation towards the twelve-week Family Medical Leave entitlement.
Accrued sick leave will be utilized against the twelve-week entitlement only for a serious health condition as qualified under the Family Medical Leave Act.
Compensatory time used during the absence does count towards the twelve weeks of FML entitlement.
The employee must use all paid leave before using LWOP unless the employee is receiving temporary disability benefit payments or
Workers' Compensation benefits.
FML and parental leave coordinate with each other and may not be "stacked".
UNPAID LEAVE
When all applicable paid leave is exhausted an employee will be placed on unpaid leave until the expiration of their coverage under the Family Medical Leave Act.
COORDINATION OF LEAVE BETWEEN SPOUSES
If both spouses are employed by the State, a combined total of twelve weeks of FML may be taken by both spouses for the birth or placement of a child.
JOB BENEFITS AND PROTECTION
During any FMLA leave, UTRGV will continue to pay the employee's health, basic life and basic accidental death and disability premiums.
If the employee chooses to retain his/her additionally selected coverage(s), he/she is required to submit payment of premium(s).
Upon return from FMLA leave, the employee will be restored to his/her original or equivalent position with equivalent pay and benefits.
UNLAWFUL ACTS BY EMPLOYERS
FMLA makes it illegal for UTRGV to:
Interfere with, restrain, or deny the exercise of any right provided under FMLA;
Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for;
Involvement in any proceeding under or relating to FMLA.
EMERGENCY FAMILY AND
MEDICAL LEAVE
The Families First Coronavirus Response Act (FFCRA or Act) requires certain employers to provide their employees with paid sick leave and expanded
family and medical leave for specified reasons related to COVID-19. These provisions are effective April 1, 2020 through December 31, 2020.
ENFORCEMENT
The U.S. Department of Labor is authorized to investigate and resolve complaints of violations. For additional information contact Human Resources or the
nearest office of the Wage and Hour Division, listed in most telephone directories under U.S. Government, Department of Labor.
Revised: April 01, 2020
Form effective: April 01 - December 31, 2020
Request for Family and Medical Leave
Last Name : First Name : Middle Name :
Employee ID : Job Title : Work Ph. :
Department : Supervisor Name :
Qualifications For FMLA Coverage
Yes No Have you been employed by the State of Texas for 12 months?
Yes No Have you worked 1,250 hours for the State of Texas in the past 12 months?
Yes No Have you taken Family and Medical Leave in the past 12 months?
If Yes, Dates FMLA was taken : Total Hours :
Leave Information
Start Date of Expected Leave :
Leave Address :
Expected Date of Return:
City:
ST: Zip Code:
Emergency Contact Name :
Relation:
Contact Ph. :
Reason For Leave
I am the spouse of a service member
I am the parent of a service member
Qualifying Exigency Leave
Emergency Family and Medical Leave
Care of a child whose school or child care provider is unavailable for reason related to COVID-19*
Yes
No
* Is your Spouse currently employed by The University of Texas Rio Grande Valley?
If Yes, FMLA provides spouses who are employed by the same employer an eligible
combined allotment of leave for the categories [*] marked
Acknowledgment
I acknowledge the above information and all other information otherwise given by me [pertaining to family or medical leave], is TRUE, COMPLETE, and
NOT MISLEADING in any way. I understand that any INCORRECT, MISLEADING or FALSE STATEMENTS furnished by me may result in sufficient cause for
denial of leave and/or disciplinary action. I hereby grant permission for UTRGV to verify information furnished by me regarding family or medical leave.
Supervisor: I acknowledge supervisor signature serves as acknowledgment that the employee referenced above requires medical leave.
Printed Employee Name
Printed Supervisor Name
Employee Signature
Date
To be completed by Patient | Employee - Not required for EFML
Supervisor Signature
Date
I authorize my licensed pra
ctitioner to release the completed Certification of Health Care Provider form to the administrators of
the Family and Medical Leave Act at The University of Texas Rio Grande Valley.
Printed Patient Name
Patient Signature Date
You may be entitled to know what information The University of Texas Rio Grande Valley [UTRGV] collects concerning you.
You may review and have UTRGV correct this information according to procedures set forth in UTS 139.
The law is found in sections 552.021, 552.023 and 559.004 of the Texas Government Code.
I am the son or daughter of a service member
I am the next of kin of a service member
Must complete certification http://www.dol.gov/whd/forms/WH-384.pdf
tThese provisions will apply April 1, 2020 through December 31, 2020
Revised: April 01, 2020
Form effective: April 01 - December 31, 2020
Phone:
Intermittent: taking leave in separate blocks of time for a single qualifying reason - or on a reduced leave schedule - reducing the employee's usual we
ekly or daily
work schedule. Employees needing intermittent/reduced schedule leave must work with their supervisor/department to schedule the le
ave so as not disrupt
department's operations, subject to the approval of the employee's health care provider.
Will this leave be?
Continuous
Intermittent
Birth of a child*
My own
Spouse
Adoption or foster care placement*
Serious health condition
My own
Spouse or parent
My child, who is under age 18 or age 18 or older and incapable of self-care because of a mental or physical disability.
Must complete certification http://www.dol.gov/whd/forms/WH-380-E.pdf
Must complete certification http://www.dol.gov/whd/forms/WH-380-F.pdf
Military caregiver leave* Must complete certification http://www.dol.gov/whd/forms/WH-385.pdf
M
ust complete certification http://www.dol.gov/whd/forms/WH-380-E.pdf
Must complete certification http://www.dol.gov/whd/forms/WH-380-F.pdf
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Your Rights under the Family and Medical Leave (University of Texas Rio Grande Valley)

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Completed 6 August 2021

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