I understand that I am applying for leave that is my right to take under The Family and Medical Leave Act (FMLA) of 1993 and 2008 amendments, or to document valid reasons for taking extended leave if I am not qualified for leave under The Family and Medical Leave Act. I understand that the designation of this leave as Family and Medical Leave may be delayed until the appropriate medical certification is received by the UNC Charlotte Benefits Office. I understand the designation of this leave as Family and Medical Leave may be denied if the appropriate forms are not received by the UNC Charlotte Benefits Office within 15 days of being asked to complete these forms, or my request for leave. I understand that I will be given seven days to provide missing paperwork or to correct missing or incomplete information on forms that were submitted, and that failure to supply this information can result in denial of my request for leave. Further, I understand that my physician and I must also complete a Fitness for Duty Certification before I can return to work if the reason for leave was either “Care for Newborn Child” or “Care for the serious health condition of (myself)” above.

If I have any sick or annual leave, I will complete the necessary leave forms designating which type of paid leave I wish to use to cover this period, if any. I understand that I may apply for Shared Leave in accordance with Personnel Information Memorandum #29. I also understand that my supervisor must approve the use of shared leave.

I agree that while I am on leave, I will continue to pay my share of the health insurance premiums, if applicable, unless I elect to discontinue coverage. I also agree that if I fail to return to work at the end of the leave period, I will reimburse the University for the cost of University-provided health benefits during my unpaid leave, if any, unless I fail to return to work because of the continuation, recurrence or onset of a serious health condition, or because of other circumstances beyond my control.

If I am unable to return to work because of my own, or my family member’s serious health condition, I will provide medical certification from the appropriate health care provider stating that I am unable to perform the functions of my position on the date that my leave expired, or that I needed to care for my spouse, child, or parent because he/she had a serious health condition, I have a qualifying exigency, or I am caregiver to a service member injured in the line of duty on the date that my leave expired. I also agree that I won’t commence work for another employer while on leave.

Finally, I understand that if I do not return to work on the date indicated above (or another date as specified by me and agreed to by the University) for reasons other than my inability to return to work due to my own serious health condition my employment may be terminated by the University as of the date my leave expired.