As We Discussed at the Onset of Your Family Medical Leave (FML), Your FML Eligibility Is

Jane Doe 1111 Smith Lane Houston, TX 77000

Dear Jane,

As we discussed at the onset of your Family Medical Leave (FML), your FML eligibility is limited to a total of [480 hours or 1040 hours], which is the equivalent of [12 or 26] weeks leave. I want to inform you of your options when your FML expires on ______(date).

It is important that you review this letter and ask me any questions you may have as failure to take action on your part prior to the expiration of your FML may result in separation from The University of Texas Health Science Center at Houston (UTHealth).

1) Return to work if released from your health care provider. Please bring the attached Certification of Fitness for Duty form with you on your return. (include a copy of the employee’s job description; the health care provider should have this to make a determination on the return to work) (Only include this provision if leave was taken for medical reasons.) 2) If you are unable to return to work on ______, you may apply for an administrative leave of absence. If you are requesting an administrative leave of absence based on your own medical condition, please contact Equal Opportunity as described below in section 4. Your leave of absence request must be received and approved prior to the expiration of your FML. 3) If you are interested in applying for sick leave hours from the sick leave pool, you should contact the Benefits Department (713) 500-3935 for an application and further information about eligibility. Your sick leave pool application must be approved before the expiration of your FML (the review process takes approximately 10 working days). 4) If you are interested in requesting an extended leave or other accommodation due to a medical condition upon your return, contact Equal Opportunity at (713) 500-3131 for an application and further information about eligibility. Your accommodation based on your medical condition must be approved before the expiration of your FML (the review process takes approximately 14 working days).

If you are unable to return to work due to a continuing illness or injury and have purchased temporary or permanent disability insurance, you should contact the Benefits Department (713) 500-3935 for assistance.

If you are unable to return to work and you have not been granted an administrative leave of absence, additional limited leave as an accommodation for a medical condition, or sick leave pool leave by (return to work date), you will be separated from UTHealth on ______at the expiration of your Family Medical Leave, in accordance with University policy.

Sincerely,

Your Title

Enclosures: HOOP Policy 106 Family and Medical Leave HOOP Policy 105 Administrative Leave of Absence HOOP Policy 37 Sick Leave Pool Program HOOP Policy 101 Disability Accommodation Certification of Fitness for Duty with Job Description (if applicable)