Dear EMPLOYEE’S NAME:

Our records indicate that your accrued personal and major medical leave (choose one: will exhaust on or was exhausted on) DATE. Please be advised that Family and Medical Leave (FMLA), which is twelve weeks of job protected leave during a fiscal year for 1) birth of a child, or the placement of a child with you for adoption or foster care; 2) a serious health condition that makes you unable to perform the essential functions for your job; or 3) a serious health condition affecting your spouse, child, or parent, for which you are needed to provide care, will be granted upon proper request. The following documents are enclosed for your use and information:

If you choose to utilize Family and Medical Leave, please complete the forms and return them to me by DATE (Note to Department Head: This date must be a minimum of 15 days from the date the employee will receive this notice. A current medical certification form should accompany each application for leave form. Leave forms should be submitted for each payroll period by the established deadline, to ensure that the employee’s pay is calculated and paid appropriately.)

A review of the enclosed policy states that the University reserves the right to approve or deny additional leave without pay after Family and Medical Leave is exhausted. Please be advised that we will approve an extended leave of absence without pay if you request it by completing an Application for Leave of Absence Without Pay, as required by University policy. (Note to Department Head: If you are not going to approve the extended leave of absence or if you are going to approve it with some restrictions, this is where you tell the employee of your intentions.)

c: Ann Bell