FMLA Checklist for Faculty and Staff

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Applying for FMLA Leave

  • Notify your supervisor or business administrator (BA) of your request for FMLA.
  • You should receive a provisional letter and the application form(s) from your supervisor or BA within five days of your request.
  • Complete the STD/FMLA Request Form (Sections A-C). It must include your time balances if you’re monthly paid, your signature, and your supervisor or BA’s signature (Section D).
  • Send the STD/FMLA Request Form via mail, fax, or email to the FMLA Administrator at least 30 days prior to your proposed leave date (or, in the event of unforeseen leave, as soon as you can) to:

FMLA Administrator
600 Franklin Building
3451 Walnut Street
Philadelphia, PA 19104-6205
Fax: 215-573-7385
Send an email

If you’re taking FMLA leave for your own serious health condition or pregnancy:

  • Have your health care provider complete the Certification of Health Care Provider for Employee’s Serious Health Condition Form (you complete Sections I and II; your health care provider completes Section III). If you’re taking leave for care of a newborn not associated with a pregnancy (father of the child or spouse) or are adopting or fostering a child, you need to submit the child’s birth certificate in lieu of a certification form.
  • Print your name on the form. Be sure your health care provider fills out the entire form. Any missing information may cause a delay in the processing of your leave request.
  • Your health care provider must send (via mail, fax, or email) the completed form to the FMLA Administrator within 20 days of your request.

If you’re taking FMLA leave to care for a family member with a serious health condition:

  • Have your family member’s health care provider complete the Certification of Health Care Provider for Family Member’s Serious Health Condition Form (you complete Sections I and II; the health care provider completes Section III). Describe the type of care you’ll provide your family member. Be sure the health care provider fills out the entire form. Any missing information may cause a delay in the processing of your leave request.
  • The health care provider must send (via mail, fax, or email) the completed form to the FMLA Administrator within 7 days of your request.

Your Certification of Health Care Provider Form must:

  • include the start and estimated end date of the leave
  • state whether the patient is incapacitated
  • include medical facts to support a serious health condition
  • be completed by the same health care provider who is providing the treatment
  • include the health care provider’s name, address, telephone number, title, medical specialty, and signature
  • be legible

If you’re taking FMLA leave for a Qualifying Exigency or Military Caregiver Leave:

  • Qualifying Exigency or Military Caregiver Leave certification forms are available for download at the Benefits Forms website.
  • Complete Section II of the Certification of Qualifying Exigency for Military Family Leave form, or Section I of the Certification for Serious Injury or Illness of a Current Servicemember, or Section I of the Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave. A Department of Defense or Veteran’s Administration health care provider must complete Section II of the Certification for Serious Injury or Illness of a Current Servicemember or the Certification for Serious Injury or Illness of a Veteran or Military Caregiver Leave form.
  • Send the completed form to the FMLA Administrator (via mail, fax, or email) within 20 days of your proposed leave date.

Getting Approval

  • The FMLA Administrator will send a letter to your home address (and an email to your supervisor or BA) indicating whether your leave is approved, denied, or incomplete.
  • Contact the FMLA Administrator by email or by phone at 215-898-1333 or 215-898-0914 if:
    • Your leave request is approved, but the dates are different than what you expected.
    • Your leave request is denied and you are unsure why.
    • Your leave request is incomplete and you are unsure what is missing. You have an additional 20 days to submit the missing documentation.

Employees approved for short-term disability are prohibited from working at the workplace or at any other location, including the employee's home, either for the University or otherwise. (Policy 404)

While on Leave

Provide the following documentation to the FMLA Administrator (via mail, fax, or email):

  • Pregnancy: A note from your health care provider with the date of delivery. Your leave dates will be adjusted based on the actual delivery date.
  • Care of newborn (father of the child or spouse): A copy of your child’s birth certificate.
  • Adoption or foster care: Court documentation.
  • Intermittent leave: Complete the Intermittent Leave Tracking Form (which lists the dates/hours you take leave) and submit updates on a monthly basis (if applicable).

Returning to Work

  • If you were out for your own serious health condition or pregnancy, your health care provider must submit a return-to-work note (via mail, email, or fax) to the FMLA Administrator and your supervisor or BA. The note must include:

     

    • The date you’re eligible to return to work
    • The health care provider’s signature
    • Any medical restrictions
  • If your return-to-work note contains restrictions that last more than one week, a copy of the note must be sent to the Office of Affirmative Action.

Office of Affirmative Action and Equal Opportunity Programs
3600 Chestnut St., Sansom Place East, Suite 228
Philadelphia, PA 19104-6106
215-898-6993 (phone)
215-746-7088 (fax)
Send an email

Normally, employees returning from leave will be reinstated to the same or an equivalent position, with equivalent pay, benefits and other terms and conditions of employment.

If You Don’t Expect to Return to Work on Time

  • Notify your supervisor or BA and the FMLA Administrator (via mail, email, or fax) immediately.
  • To extend your leave, request one of the following from the health care provider:

  • If your serious medical condition becomes long-term in nature, consider contacting Melissa A. Smith, Human Resources Benefits Specialist via email or at 215-898-1326; or Geri Zima, Manager, Benefits Administration via email or at 215-898-1331. They can discuss the application process for Long-Term Disability should that become necessary.