Dear X:

We have received your request dated X to take time off from work under circumstances that may qualify for leave under the Family and Medical Leave Act (FMLA). Enclosed is information on the FMLA. Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid, job protected, leave in a 12-month period for qualifying reasons with the certification of a physician. (Leave may be granted on a reduced leave schedule if there is medical need for such leave and the certification supports it.) Also, your health benefits must be maintained during any period of unpaid FMLA leave under the same conditions as if you continued to work, and you must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from leave. If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave; or (2) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA leave.

This is to inform you that:

  1. You may be eligible for FMLA and may have a qualifying reason to utilize leave under the provision.
  1. The requested leave will be counted against your annual FMLA leave entitlement.
  1. You will be required to furnish medical certification of a serious health condition. Please furnish certification to the OSU Human Resource department by XX/XX/XXXX (15 days out),or we may delay the commencement of your leave until the certification is submitted.
  2. Payment for time off during FMLA will be paid under appropriate leave policies.
  1. (a) If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of FMLA leave.

(b) We will continue to pay premiums on employer-paid benefits such as life insurance and employee health while you are on FMLA leave. When you return from leave you will not be expected to reimburse us for the payments made on your behalf.

(c) If you do not return to work after FMLA leave, you may be required to reimburse OSU for benefit premiums paid on your behalf.

6. As described in 825.218 of the FMLA regulations concerning key employees, we have determined that restoring you to employment at the conclusion of FMLA leave will not cause substantial and grievous economic harm to the University.

7. While on leave, you will be required to furnish us with periodic reports regarding your status and intent to return to work. If the circumstances of your leave change and you are able to return to work earlier than the date indicated, please notify us at least two work days prior to the date you intend to report for work. If there is a change in your condition that will require you to be off work longer than was initially indicated, you will need to notify us immediately and provide additional certification forms from the treating physician.

  1. You will be required to furnish recertification relating to a serious health condition.

Attached are three forms:

  • Notice of Eligibility and Rights & Responsibilities (Form WH381)
  • Certification of Health Care Provider for Family Member’s Serious Health Condition (Form WH-380-F)
  • Declaration of Relationship

Part A of the Notice of Eligibility and Rights & Responsibilities (Form WH381) states that you are eligible for FML. Part B provides information about whether you are able or required to substitute paid leave for unpaid leave and any responsibilities you may have while on leave. Please read this Notice carefully.

Please complete the Section II of the enclosed form, Certification of Health Care Provider (Form WH380F). Also, please have your health care provider complete Section III of the Certification. The Certification form and the Declaration of Relation Form is to be completed and returned to Human Resources, 106F Whitehurst or fax to me at 405 744-8345 within 15 calendar days of this request. Failure to provide the required documentation may result in delay or denial of leave.

Please let us know if there is anything that we can do to help you during this time. If you have any questions regarding the FMLA policy or benefits, please contact me at 405-744-7401.


HR Generalist

Cc: Employee Services

Additional Resources:

  • FMLA Policy 3-0708 Link
  • Department of Labor FMLA Employee Guide
  • ComPsych Employee Assistance Program– Resources and information for personal and work-life issues that is no cost to benefits eligible employees and their dependents.
  • Long Term Disability