Family Medical Leave Act (FMLA) / Disability
This section of the Utica College website contains information and forms for Family Medical Leave (FMLA)/Disability leave in case of your own serious illness or if you need to be the primary caregiver for one of your dependents (as defined by the FMLA). When you have advance notice that you will be in need of FMLA, federal law requires that you give your employer 30 days’ notice of your intent to use family medical leave. In case of emergencies in which 30-days’ notice will not be possible, it is always best practice to give your immediate supervisor and Human Resources as much notice as practical as to when you will be out for FMLA/Disability. Disability is defined as any medical absence of more than 5 business days.
Utica College Family Medical Leave Policy
Utica College Sick Leave Procedure
Request for FMLAThis form needs to be completed by you and your supervisor and returned to the Office of Human Resources.
Statement of Rights – Disability Benefits LawNo action required.
Notice and Proof of Claim for Disability Benefits (DB-450)To be used in all cases of an employee’s own medical disability, regardless of how long the employee has been at Utica College. Employee completes Part A and physician/health care provider completes Part B and returns the form to the Office of Human Resources as soon as the disability begins. This form is then forwarded to the disability company and is the trigger for disability payments, if any, therefore its timely completion and return to this office is essential. This form is applicable even for AAUP members who are on salary continuation during their disability. Form can be faxed to 315-792-3386; mailed to The Office of Human Resources, Utica College, 1600 Burrstone Road, Utica, NY 13502; or scanned and emailed to HR@utica.edu.
Employee Rights and Responsibilities Under the Family Medical Leave Act (WHD Publication 1420). No action required.
Notice of Eligibility and Rights & Responsibilities (WH-381). Example only. You will receive this from the Office of Human Resources. Please read the back page carefully as it explains how your wages are handled during your disability.
- Next is the
Certification of Health Care Provider (
). Your Healthcare Provider completes this and the doctor should return to this office within 15 days of the disability. Choose E if it is your own disability, choose F if it is a qualifying family member’s disability.
Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave (WH-385). To be used when the leave is requested for the illness of a covered service member. Form should be returned to the Office of Human Resources within 15 days of the request of FMLA.
Certification for a Serious Injury of Illness of a Veteran for Military Caregiver Leave (WH-385-V). To be used when the leave is requested for a Caregiver due to the serious injury or illness of a covered veteran. Form should be returned to the Office of Human Resources within 15 days of the request of FMLA.
Certification of Qualifying Exigency For Military Family Leave (WH-384). To be used to request a qualifying exigency for FMLA leave. Form should be returned to the Office of Human Resources within 15 days of the request of FMLA.
- The last paper is a sample
Return to Work form. Your physician may choose to do something different, but a note from your doctor clearing you to return to work will be required if your leave was due to your own serious injury or illness.