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family _ medical leave act _fmla_

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					                                 Family & Medical Leave Act (FMLA)
                                             Checklist

Employee Name:                                                                  EmplID # :

Department:                                                     Supervisor:


Employee Eligibility:

Employee has worked 12 months for the University of Missouri,                                 No    Yes

And employee has worked 1250 hours in the previous 12-month period.                           No    Yes

Employee eligible for FMLA, if 'Yes' to both of the above.                                    No    Yes


Paid Leave Balances as of Last Day Worked: (Last Day Worked : __________________________)

Vacation (Hours)           Sick (Hours)                 Family Sick (Hours)             Personal (Hours)

_____________              _____________                ______________                  _____________


FMLA Leave Balances: Initial FMLA Begin Date: _____________

FMLA Leave used during current FMLA year:                      ______ weeks ______ days ______ hours

FMLA Leave available during current FMLA year:                 ______ weeks ______ days ______ hours
 (Maximum of 12 weeks or 480 hours based on 100% FTE)


 (Date)       Process Checklist for employee requesting FMLA

              Letter to Employee explaining rights, conditions, etc.

              Monthly Absence Summary or Biweekly Payroll Time Record, completed

              Personnel Action Form (PAF) - process when employee goes out on FMLA (see PAF Guide
              for processing of PLOA/LOA)

              Request for Leave of Absence Form, UM Form 108 - attach to PAF

              Vacation/Sick Leave System - Verify accruals have been frozen. Make adjustments to
              accruals as necessary through Web Time.

              Physician/Practitioner/Health Care Provider Certification form returned

              Fitness for Duty Certification, required for employee returning to work


 (Date)       Process Checklist for employee returning to work

              Personnel Action Form (PAF) - process to return employee to active status (see PAF guide
              for processing a RLOA)

              Vacation/Sick Leave System - Verify accruals have been activated. Make adjustments to
              accruals as necessary through Web Time.


Additional Comments:
Rev. 2/06
Rev. 2/06