FMLA UTILIZATION FORM
(Guidelines to Complete)
| Purpose: |
To record and document a faculty/staff member’s use of FMLA leave. These forms should be completed during paid or unpaid leaves. A separate utilization form must be completed for each month the individual is on leave. |
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NOTE: FMLA Utilization Forms provide the department, as well as the University, with the necessary documentation of FMLA leave utilization. Without documentation proving leave utilization, a faculty/staff member’s leave "bank" will continue to show the full 12-week entitlement. The department is financially responsible for an individual’s health care coverage while on approved FMLA leave for as long as the FMLA leave "bank" shows available hours. |
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NOTE: If the faculty/staff member would not normally be expected to report to work if he/she were not on FMLA leave (e.g., summer layoff), the supervisor cannot count that time as FMLA leave. |
| Who: |
Supervisor responsibility to track FMLA leave and send monthly utilization form to Human Resource Records Management (HRRM). |
| When: |
The department reports FMLA utilization monthly. |
Complete:
- Fill in the name and social security number of the faculty/staff member that utilized FMLA leave, as well as the dates of the leave and the number of hours taken
- Fill in the month and year being reported
- Dates: If the leave includes consecutive days of absence, it is not necessary to document each date on the form … an inclusive date-range is sufficient with indication of the total number of hours
- The number of hours is particularly important considering intermittent leaves. Whole days of leave should be recorded as hours equal to the number of scheduled hours missed by the faculty or staff member.
- Fill in the reason code to reflect leave as follows:
| Code |
Reason |
| 1 |
Illness, Self |
| 2 |
Illness, Spouse |
| 3 |
Illness, Dependent Child |
| 4 |
Illness, Parent |
| 5 |
Birth, Adoption, or Foster Placement |
- Fill in the total number of hours (tally all reasons) used by the faculty/staff member during the month
- Fill in the name of the department
- Provide the signature of the person in the department who is authorized to grant leave-of-absence.
Once completed, make a copy of the form for departmental records, then send original form to Human Resource Records Management (HRRM). NOTE: FMLA utilization is confidential and not to be shared with anyone. FMLA utilization cannot be used to impact employment decisions. For additional information, please contact Employee Relations.
NOTE: Remember to complete a PAF when a faculty/staff member enters unpaid leave status. When completing the PAF, be sure to note in the remarks section that the faculty/staff member is entering unpaid leave status utilizing FMLA leave |
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to principles of equal opportunity and affirmative action.
HR Express
2525 West End Ave Suite 218
Nashville TN 37203
Hours M-F 7:30 - 5:30
Last Updated:
October 19, 2009
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