DRAFT
To:
From:
Date:
Subject:
On approximately [ Date ], you notified us of your need to take family/medical leave due to a serious health condition that makes you unable to perform the essential functions of your job*.
You notified us that you need this leave beginning on [ Date ] and that you expect leave to continue until or about [ Date ].
You have the right under the FMLA for up to twelve weeks of unpaid leave. You will be required to first use your accrued paid sick leave and vacation time as part of the period of medical leave. The University will continue its contribution to the premiums for your hospital-medical-surgical and dental benefits while you are on leave. These benefits will be maintained under the same conditions as if you continued to work. (See the University Policies and Procedures, Family Medical Leave, Maternity Leave, and Medical Leave for more information.)
If you pay a
portion of the premiums for health or dental insurance, you will need to
contact the Benefits Office, 831-2913, regarding the continuation of other
benefits (e.g. life insurance, disability insurance, etc.).
(The following items are recommended,
but not required)
You will be required to provide documentation of a serious health condition. Please furnish this certificate by [ Date {minimum of 15 days to return the information}]. Moreover, you will be required to present a fitness-for-duty certification prior to being restored to employment.
While on leave, we will appreciate and welcome periodic reports of your progress and intent to return to work every thirty days. If the circumstances of your leave change and you are able to return to work earlier than the date indicated in this memorandum, we will be delighted and ask that you provide as much advance notice as possible, at least a couple of days.
[* Insert the appropriate reason for the leave]