UNIVERSITY OF HOUSTON-VICTORIA
              APPLICATION FOR FAMILY AND MEDICAL LEAVE OR PARENTAL LEAVE

Request for family or medical leave or parental leave must be made, if practical, at least 30 days prior to
the date requested leave is to begin.    PLEASE PRINT

I. Personal Data

Employee Name_______________________________ Social Security Number___________________

Home Address______________________________________________ Phone No. _______________

Employing Department_________________________________ Supervisor______________________

I am employed at another UH Component: ______Yes _______No

My spouse is employed at UH-Victoria or another UH Component: ___Yes ___No

If yes; name of UH Component:________________________________________________________

This is a joint application with my spouse. ______Yes ______No

II. Leave Request Summary: Family and Medical Leave__________     Parental Leave_________

Qualifying Condition (Mark the appropriate statement)
________ The birth of a child of the employee, and the care of the newborn.
________ The placement of a child with an employee in connection with the adoption or state-approved 
                  foster care of the child by the employee.
________ The serious health condition of a child, parent, or spouse of the employee (FML only)
________ A serious health condition of the employee (FML only)

Supporting Documents Attached
________ A medical certification from the health care provider
________ A copy of the legal orders of adoption or placement

Amount of family or medical or parental leave requested (cannot exceed 12 weeks): ______________
Start date of leave:__________________________Expected return to work date:_______________

Leave schedule for intermittent or reduced leave (If applicable; subject to supervisor's approval):
_______________________________________________________________________________

Prior family or medical leave or parental leave taken in previous 12 months:_______________weeks/days.

I understand and agree to the following provisions:

• For Family and Medical Leave: I have worked for the State of Texas at least 12 months and for UHV at 
  least 1,250 hours in the previous 12 months. If less than that amount, I am eligible for Parental Leave for 
  birth or placement of a child.

• If I fail to return to work after the leave for reasons other than the continuation, recurrence or onset of a 
  serious health condition that would entitle me to medical leave or other circumstances beyond my control, 
  and if my employer requires it, I will be financially responsible for the medical insurance premiums the 
  company paid while I was on leave.

• I must exhaust all sick, vacation, or other paid leave accumulation while taking FMLA leave. In the case 
  of my own disability, payment will occur under a company disability insurance plan, if I am so covered.

• After 12 weeks or amount of approved leave, if I do not return to work or contact my supervisor or 
  manager on or before the date intended, it will be considered that I abandoned my job.

• I should report periodically during the leave (at least once per week) to my supervisor on my leave status 
  and intention to return to work.

• I will receive the state credit for health insurance during the family or medical or parental leave and will be 
  billed for any additional insurance premiums due.

• Should I fail to pay additional premiums health insurance coverage will be changed to employee only level 
  and optional coverage cancelled.

• Continuation of group insurance is subject to the conditions and policies of ERS relating to coverage while 
  on leave without pay.

• I must provide a release to return to work from my physician following my leave. Should I fail to do so, my 
  department may deny restoration of employment.

Signature of employee________________________________________ Date_____________________

III. To Be Completed by the Department

Employee's Job Title____________________________________FTE________Hire date____________

Pay type: _____Monthly _____Biweekly   Normal months worked per year:  12___9____Other________

Date of event or onset of condition___________________Last day worked_______________________

Vacation balance at last day worked _________hrs.  Sick leave balance at last day worked _________hrs.

FML/Parental Leave is approved with pay from_______________________ to______________________

FML/Parental Leave is approved without pay from_____________________ to______________________

Total weeks of approved FML or Parental Leave_________________________

For intermittent or reduced leave, the following schedule is approved:_______________________________

___________________________________________________________________________________

Family and Medical or Parental Leave taken during the previous 12 months:  _____________weeks/days

Family and Medical or Parental Leave is disapproved for the following reason (s):
___________________________________________________________________________________
__________________________________________________________________

Supervisor Signature___________________________________________Date_____________________

IV. Human Resources Department Acknowledgement

• The Human Resources Department acknowledges __________ weeks of FML or Parental Leave as 
  approved by the department.

• Any changes in the approved leave must be reported immediately to the Human Resources Department.

• A Personnel Action Request (PAR) is required to place the employee on leave without pay and should be
  submitted in a timely manner to the Human Resources Department.

• The employee will be given state premium sharing toward the cost of health insurance while on family and 
  medical or parental leave.

• All group insurance will be deducted form sick and/or vacation pay.

• The employee will be billed for additional insurance premiums in excess of the state premium sharing.

• Should the employee fail to pay additional premiums, health coverage will be charged to the employee only 
  level and optional coverage will be terminated.

• Continuation of group insurance is subject to the conditions and policies of ERS relating to coverage while on 
  leave without pay.

• The Human Resources Department may request the department to provide leave records on the employee 
  if necessary for processing benefits including, but not limited to, disability applications, workers compensation 
  claims, and life claims. 

Signature of HR Representative___________________________________  Date__________________