University of Tennessee, Knoxville

University of Tennessee, Knoxville | Human Resources

Family Medical Leave (FML) and/or Paid Parental Leave (PPL) Request Form

FML and/or PPL Request Form

Please complete this secure form to request FML and/or PPL. Qualified leave may be based on a serious health condition; birth, adoption or foster child placement; or to care for a family member with a qualifying medical condition. If you have questions please contact Human Resources at 865-974-6642 or FamilyMedicalLeave@utk.edu.

Please note that if you are requesting FML for a medical condition that is not childbirth, adoption, or foster care placement, you and your medical provider are required to fill out this form.

Personnel Number*

Last Name*

First Name*

Street Address*

City*

State Abbreviation (Two Letters)*

Zip Code*

Phone Number:*

Phone

UTK Email:*

Department*

Supervisor Name*

Supervisor Email*

Leave Category*

*Please call Human Resources about "Qualifying Exigency" if you think this option applies to you: 865-974-6642

Parental Leave

Medical Leave - Self

Medical Leave - Family

Qualifying Exigency (Armed Services)*

Active Military Duty Orders

Please attach a copy of the active military member’s active duty orders:

Drag and drop files here or

Medical Certifcate Required

Choosing this leave category requires a medical certification. You and your provider should fill out this form.

Family Member Relationship:

Spouse

Parent (or Parental Figure)

Child

Child's birth date:

Parental Leave Type:

Childbirth (Maternity or Paternity)

Adoption

Foster Care Placement (FML only, not eligible for PPL)

Please Acknowledge:

I understand I have 30 days from the date of birth or adoption to contact the Payroll Office at 865-974-5251 to add my child to my group medical insurance, if applicable.

How will you be using this leave?*

Intermittently – taking leave in separate blocks of time

Consecutively – taking leave in a continuous block of time

Intermittently

Consecutively

Estimated FML Start Date:*

Would you like to retain any sick leave hours for when you return?*

FMLA policy allows you to keep up to 5 days or 40 hours of sick leave, whichever is less, for use outside of the FML reason

Yes

How many hours would you like to retain (up to one week's worth of hours)?

What is your preferred method of communication?*

Phone Call

How do you prefer to receive your approval letter?*

Mailed to Provided Address

UTK Email

Please type your type your full name below to agree to the following:*

I understand the University will pay the employer portion of the group medical insurance premium for up to 12 weeks of any leave that qualifies under the Family and Medical Leave Act of 1993 and the employee portion will continue to be deducted from my paycheck provided I use paid parental leave or my leave accruals to remain in paid status. After exhausting my leave, I understand I must pay the employee portion in advance to the Treasurer’s Office 400 W Summit Hill Dr., UT Tower 10th Floor, Knoxville, TN, 37902 to maintain coverage.

I understand if I run out of leave accruals and am placed in an unpaid leave status, I will be responsible for paying my portion of my group medical insurance premiums directly to the Treasurer’s Office or my coverage will lapse. I also understand all other insurance plans must be fully paid by me while on leave without pay. While on FML, if on leave without pay, I understand I will not accrue leave or receive retirement creditable service. I understand the time requested, paid or unpaid, will count against my 12 weeks of FML during this 12-month period. Finally, I understand that if I exhaust all leave and enter unpaid status, it is my responsibility to contact Payroll, Benefits, and Retirement at 865-974-5251 to determine how and when to arrange payments for continued insurance coverage.

Thank you!

Thank you for completing our electronic FML and/or PPL request form! We recommend that you click the box below to receive a copy of your responses.

Submitting this form will automatically alert your supervisor of your plan to use FML and/or PPL leave. They will be notified of your estimated start date and leave type. You are responsible for communicating all absences to your supervisor according to departmental policies.

If you have questions please contact Human Resources at 865-974-6642 or FamilyMedicalLeave@utk.edu.

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