FML Checklist Cover 2017

2017 FML Checklist Cover Dept. Contacts:

Employee Name: ____________________________________________________ SPVR:

Empl ID: _______________ Date request was received: ___________________ DBA:
Contact Email:

Staff ___ Faculty___ FTE: ____ FT___ PT ___ Monthly ____ BW ____ CBA:
Employee most recent hire date: ____________________ DEPT:
FML within the past 12 months? Yes No

If yes, dates: ________________________________________________________

Total amount of time used: ____________________________________________

Full Time FMLA: Intermittent Time:

Sick Available: __________________ Vacation Available: ________________ Total: ____________________

Paid LOA: Unpaid LOA:

Paid FMLA ePAR:__________________________ Unpaid FMLA ePAR:

Was employee placed on LOA in ERS? __________ Effective Date:

NOTE:

January February March April Sa
Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr 1
8
1234567 123 4 123 4 2 34567 15
8 9 10 11 12 13 14 5 6 7 8 9 10 11 5 6 7 8 9 10 11 9 10 11 12 13 14 22
15 16 17 18 19 20 21 12 13 14 15 16 17 18 12 13 14 15 16 17 18 16 17 18 19 20 21 29
22 23 24 25 26 27 28 19 20 21 22 23 24 25 19 20 21 22 23 24 25 23 24 25 26 27 28
29 30 31 26 27 28 26 27 28 29 30 31 30

May June July August Sa
Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr 5
12
123456 12 3 1 1234 19
7 8 9 10 11 12 13 4 5 6 7 8 9 10 234567 8 6 7 8 9 10 11 26
14 15 16 17 18 19 20 11 12 13 14 15 16 17 9 10 11 12 13 14 15 13 14 15 16 17 18
21 22 23 24 25 26 27 18 19 20 21 22 23 24 16 17 18 19 20 21 22 20 21 22 23 24 25
28 29 30 31 25 26 27 28 29 30 23 24 25 26 27 28 29 27 28 29 30 31
30 31

September Sa October November Sa December Sa
Su Mo Tu We Th Fr 2 Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr 4 Su Mo Tu We Th Fr 2
9 11 9
1 16 123456 7 123 18 1 16
345678 23 8 9 10 11 12 13 14 5 6 7 8 9 10 25 3 45678 23
10 11 12 13 14 15 30 15 16 17 18 19 20 21 12 13 14 15 16 17 10 11 12 13 14 15 30
17 18 19 20 21 22 22 23 24 25 26 27 28 19 20 21 22 23 24 17 18 19 20 21 22
24 25 26 27 28 29 29 30 31 26 27 28 29 30 24 25 26 27 28 29
31

O = UH holiday; if employee is out on paid leave during holiday – receive holiday pay & FML paid leave gets extended
X = Time not to be counted toward FML; MAPP 02.02.01 IV C