REQUEST FOR UNPAID FMLA LEAVE
(Last Revised: 12/21/05)

Within two (2) business days of an employee's initial request for unpaid FMLA leave, the supervisor must provide the employee with information about the FMLA, the specific expectations and obligations of the employee under the FMLA, and the consequences of failing to meet those obligations. A supervisor must confirm or deny, in writing to the employee, within two (2) business days after receiving a request whether the employee is eligible to take unpaid FMLA leave. The employee is presumed eligible unless the supervisor notifies the employee of ineligibility.

Department: ______________________________________________ Date:___________________________________

Name of Employee Requesting Leave: ___________________________SSN#_________________________________

Please state the reason for requesting FMLA leave. For more information refer to Section 3. of this policy.

_______________________________________________________________________________________________

Requested dates of FMLA leave: Beginning Date: _____________________ Ending Date: ______________________

1. This leave will be counted against the employee's annual twelve (12) week FMLA entitlement.

2. The University will require medical certification to support a request for FMLA leave for medical reasons. If a certification is requested and not supplied, the employee's request for leave will be denied.

3. The employee may use annual and sick leave in place of unpaid FMLA leave, but is not required to do so. Catastrophic leave and time off under Workers' Compensation will be counted against the employee's annual twelve (12) week FMLA entitlement.

4. An employee who carries health and/or life insurance through the University must pay his or her portion of insurance premiums while on unpaid leave. The University will mail the employee a monthly bill showing the amount due.

5. If an employee fails to return within three (3) work days after an approved leave, including any approved extensions, the employee will be considered to have resigned. Refer to Section 2.1. "Separation of Employment" Policy 3225, UBP.

6. An employee returning to work following unpaid FMLA leave due to his or her own serious health condition must submit a physician's statement certifying that the employee can return to work and can perform the essential functions of the job, with or without reasonable accommodations.

7. The employee's department must reinstate the employee returning from unpaid FMLA leave to the same or equivalent position with equivalent pay, benefits, and other employment terms and conditions.

I understand the conditions of unpaid FMLA leave listed above.

Employee Signature___________________________________________ Date ____________________________

I am aware of this request for unpaid FMLA leave and recognize the employee is entitled to unpaid FMLA leave up to twelve (12) weeks within a twelve (12) month rolling period. I also realize that the employee's job, salary, and benefits are protected for those twelve (12) weeks. I have given the employee a copy of "Family and Medical Leave" Policy 3440, UBP.

Supervisor Signature __________________________________________Date _____________________________

*Send a copy of this form to the UNM Human Resources Service Center @ 1730 Lomas Blvd. NE.

Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm