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FMLA and VESSA Information for Departments
(For Departmental Use Only)

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@illinois.edu.

FMLA Form and Instructions: The FMLA form is used to grant eligible employees up to 12-weeks entitlement for the birth or adoption of a child; for the care of a child, spouse, or parent who has a serious health condition; or when an employee is unable to perform the function of his or her position due to a serious health condition. 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 Format which requires Adobe Acrobat Reader; FMLA Form in Rich Text Format (RTF) for download

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

VESSA Form and Instructions: The 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 Format which requires Adobe Acrobat Reader; VESSA Form in Rich Text Format (RTF) for download

FMLA Medical Certification in PDF Format which requires Adobe Acrobat Reader
FMLA Medical Certification 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

Supplemental Departmental Review Form: Departments should use this form in conjunction with an employee’s FML form if the employee submits an old FML form (as opposed to the current version, which includes the TO BE COMPLETED BY THE DEPARTMENT section). No changes should be made to this form.; PDF format Form in PDF Format which requires Adobe Acrobat Reader; RTF format Form in Rich Text Format (RTF) for download

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

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

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

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

Provisional Approval Letter for Serious Health Conditional or 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 format Form in PDF Format which requires Adobe Acrobat Reader; RTF format Form in Rich Text Format (RTF) for download

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

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

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

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

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

Campus-Wide FMLA/VESSA Training PowerPoint Presentation: in PDF Format which requires Adobe Acrobat Reader; Updated 04/30/2004
Departments should refer to the PowerPoint presentation as a guide for updated information regarding FMLA and VESSA (e.g., background, entitlement, eligibility, initiation—employee vs. employer, approval process, recertification, and returning from FMLA and VESSA).