As We Discussed at the Onset of Your Family Medical Leave (FML), FML Is Limited to a Total

Date

Jane Doe

1111 Smith Lane

Houston, TX 77000

Dear Jane,

As we discussed at the onset of your Family Medical Leave (FML), FML is limited to a total of [480 hours or 1040 hours], which is the equivalent of [12 or 26] weeks leave. I want to inform you of your options when your FML expires on ______(date). {This could vary for the birth of a child.}

1) Return to work if released from your physician. Please bring the attached Certification of Fitness for Duty form with you on your return. (include a copy of the employee’s job description; the physician or practitioner should have this to make a determination on the return to work) (Only include this provision if leave was taken for medical reasons.)

2) If you are unable to return to work on ______, you may apply for a Leave of Absence. Please include a physician's statement regarding your continued need for a leave (if the justification for your leave is for medical reasons). Your leave of absence request must be received and approved prior to the expiration of your FML.

3) If you are interested in applying for sick leave hours from the sick leave pool, you should contact the Benefits Department (713) 500-3935 for an application and further information about eligibility. Your sick leave pool application must be approved before the expiration of your FML (the review process takes approximately 10 working days).

4) If you are interested in requesting an extended leave or other accommodation due to a disability, contact the Equal Opportunity Advisor in Human Resources at (713) 500-3416 for an application and further information about eligibility. Your disability accommodation must be approved before the expiration of your FML (the review process takes approximately 14 working days).

If you are unable to return to work due to a continuing illness or injury and have disability insurance, you should contact the Benefits Department (713) 500-3935 for assistance.

If you are unable to return to work and you have not been granted a leave of absence, a disability leave, or sick leave pool by (return to work date), you will be separated from The University of Texas Health Science Center at Houston on ______at the expiration of your Family Medical Leave, in accordance with University policy.

Sincerely,

Your Title

Enclosures:

HOOP Policy 106 Family Medical Leave Act

HOOP Policy 105 Leave of Absence

HOOP Policy 37 Sick Leave Pool Program

HOOP Policy 101 Disability Accommodation

Certification of Fitness for Duty with Job Description (if applicable)