Forms

FMLA and VESSA Information for Departments

Departments have the option to send completed FMLA/VESSA Usage Reports as well as the Approval + Reason/Type of Leave letter to the Records Section at SHR by sending an email to fmla@uillinois.edu.

FMLA Form and Instructions

The Family and Medical Leave Act (FMLA) form is used to grant eligible employees up to 12 weeks of leave entitlement for the birth or adoption of a child; for the care of a child, spouse, or parent who has a serious health condition; when an employee is unable to perform the function of his or her position due to a serious health condition; or for a qualify military-related exigency; or up to 26 weeks of leave entitlement for the care of an ill/injured covered servicemember.

Carefully read all instructions pertaining to the FMLA form before proceeding with the approval/denial process. FMLA leaves are granted by the department/unit.

FMLA Form in PDF which requires Adobe Acrobat Reader
FMLA Form in Rich Text Format (RTF) for download

Medical and Military Certification Forms:
For Employee’s Serious Health Condition: PDF | RTF
For Family Member’s Serious Health Condition: PDF | RTF
For Serious Injury or Illness of Covered Servicemember: PDF | RTF
For Qualifying Exigency for Military Family Leave: PDF | RTF

VESSA Form and Instructions

The Victims’ Economic Security and Safety Act (VESSA) form is used to grant eligible employees up to 12 weeks entitlement to employees who are victims of domestic or sexual violence or who have a family or household member who is a victim.

Carefully read all instructions pertaining to the VESSA form before proceeding with the approval/denial process. VESSA leaves are granted by the department/unit.

VESSA Form in PDF which requires Adobe Acrobat Reader
VESSA Form in Rich Text Format (RTF) for download

FMLA/VESSA Usage Report
All FMLA and VESSA hours used by an employee for an approved leave(s) should be tracked by the department via the Usage Report. Select the appropriate Civil Service Usage report (FMLA, VESSA, or FMLA/VESSA Concurrent) by clicking on the respective tab at the bottom of the spreadsheet. It is important that departments complete each section of the Usage Report.

FMLA/VESSA Usage Report in Excel Format

Sample FMLA and VESSA Letters — The following sample letters should be used as a method of communication between you (the department) and the employee regarding the status of an FMLA application.

  • Approval + Reason/Type of Leave (FMLA)
    Departments should use this form to inform an employee of her/his FMLA approval as well as the type of leave and reason for the leave. No changes should be made to this form. (PDF) | (RTF)
  • Approval + Reason/Type of Leave (VESSA)
    Departments should use this form to inform an employee of her/his VESSA approval as well as the type of leave and reason for the leave. No changes should be made to this form. (PDF) | (RTF)
  • Leave Time Designated as FMLA
    Departments should use this “sample letter” to inform an employee that her/his absence is being designated as Family and Medical Leave. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Provisional Approval Letter for Potential Serious Health Condition of the Employee
    Departments should use this letter to notify an employee that her/his absence may qualify as a “serious health condition” under FMLA, and the department is granting provisional approval to the employee until an FML form and medical certification has been submitted by the employee and reviewed by the department. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Provisional Approval Letter for Serious Health Condition of the Employee
    Departments should use this letter to notify an employee that her/his absence, based on discussions between the department and the employee, qualifies as a “serious health condition” under FMLA, and the department is granting provisional approval to the employee until an FML form and medical certification has been submitted by the employee and reviewed by the department. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Denial Letter Due to Medical Certification
    Departments should use this letter to notify an employee that her/his FML request is being denied because the medical certification does not support the type of leave requested. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Denial Due to Time Worked
    Departments should use this letter to notify an employee that her/his FML request is being denied because the employee has not worked for the university at least one year and worked 1,250 hours during the preceding twelve months. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Denial Due to Non-Qualified Relationship
    Departments should use this letter to notify an employee that her/his FML request is being denied because the family member’s relationship to the employee does not qualify under FMLA. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Notification of Leave Expiration
    Departments should use this letter to notify an employee that her/his Leave entitlement under FMLA will expire on the indicated date (included in the letter). Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)
  • Notification That the Employee Has Exhausted FMLA Leave Entitlement
    Departments should use this letter to notify an employee that her/his leave entitlement under FMLA has been exhausted and the employee is expected to return to work with a full medical release. Departments may change the wording of this letter since it is a “sample” letter and should be used as a guide for each case. (PDF) | (RTF)