University of California, Riverside

Academic Personnel



FMLA Forms


Click on the icon to download a copy of each document in Microsoft Word and/or Adobe Acrobat format.


FML Checklist for Academic Employees (March 2015)
The purpose of this checklist to assist your department in evaluating leave requests and administering Family and Medical Leave.

Leave of Absence Request Form (July 2010)
The purpose of this form is to document the leave request.
Academic Leave Form (UPAY 573)
This form serves several purposes:

  1. It can be used by an employee to request leave for any purpose and to specify preferred pay options during the leave.
  2. It is used by the department to document approval or denial of leave, and whether the leave is to be considered Family and Medical leave. It also provides a record of the pay status during the leave.
  3. It provides essential documentation for continuation of employee benefits during a Family and Medical Leave.

Notice of Eligibility and Rights and Responsibilities – Family Medical Leave Act (July 2010)
This document is used to inform an employee of her or his rights under the Family and Medical Leave Act of 1993. When an employee provides notice of the need for leave for reasons covered by FMLA, the University must provide the employee with this notice or its equivalent pursuant to 29 C.F.R. § 825.300(b), (c).

Certification of Health Care Provider for Employee’s Serious Health Condition (March 2011)
Provides documentation of the employee’s need for the leave. Employees must provide this to their health care provider, who should return it to the department. If leave is due to an employee's own serious health condition, a copy of the employee¹s job description should be attached.

Certification of Health Care Provider for Family Member’s Serious Health Condition (March 2011)
Provides documentation to support employee’s request for a leave due to a family member’s serious health condition. Employees must provide this to their health care provider, who should return it to the department. This needs to be accompanied with a Declaration of Relationship (see below).

Certification of Health Care Provider for Employee’s Pregnancy Disability (March 2011)
Provides documentation to support employee’s request for Pregnancy Disability Leave (PDL) due to pregnancy, childbirth or related medical condition.  Employees must provide this to their health care provider, who should return it to the department.

Certification of Qualifying Exigency for Military Leave (July 2010)
Provides documentation to support employee’s request for a leave while the employee’s child or parent is on active duty or call to active duty status.  Employees must provide this to their health care provider, who should return it to the department.

Certification for Serious Injury or Illness of Covered Servicemember (July 2010 )
Provides documentation to support employee’s request for a leave due to a serious injury or illness of a covered servicemember.  Employees must provide this to their health care provider, who should return it to the department. If leave is due to a family member’s serious health condition, a Declaration of Relationship.

Declaration of Relationship (July 2010)
Provides documentation to confirm family relationship when an employee requests for a leave due to a family member’s serious health condition or parental leave.  For leaves due to a family member's serious health condition, this accompanies a Certification of Health Care Provider for Family Member’s Serious Health Condition.

Family and Medical Leave Return to Work Certification (March 2011)
Provides documentation that the employee is able to return to work. A job description should be attached to this when it is provided to the employee. Keep in mind that certification of an employee's ability to return to work may be required only where a department has a uniformly-applied policy or practice that requires all similarly-situated employees to provide such certification.

Family and Medical Leave (FML) Factsheet (January 2017)
Provides information for employees about their benefits while they are on Family and Medical leave.

For more information on Academic Leaves of Absence, click on this link: http://academicpersonnel.ucr.edu/leaves/.

More Information

General Campus Information

University of California, Riverside
900 University Ave.
Riverside, CA 92521
Tel: (951) 827-1012

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Department Information

Academic Personnel
2148 Hinderaker Hall
Riverside, CA 92521

Tel: (951) 827-2933
Fax: (951) 827-3659
E-mail: academicpersonnel@ucr.edu

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