a letter from the Department Chair detailing the duties you will
be assigned upon your return from leave.
a form from the Benefits Office stipulating the arrangements for health and retirement benefits, if the faculty member is using unpaid leave and chooses to continue employer-subsidized health care benefits with UMD during the leave.
if appropriate, legal documentation of adoption or foster care
of a child.
if appropriate, medical documentation that includes a statement
of medical facts meeting the criteria for serious medical conditions
as defined by the Policy on Family and Medical Leave, including:
the date the condition commenced;
the regiment of treatment to be prescribed;
the estimated duration of absence from work;
in the case of the faculty member's serious health condition,
certification that the faculty member is unable to perform the
essential functions of his/her position, using the appropriate U.S. Department of Labor form(note that in some browsers, you may need to download this form before you can fill it out; to download, right-click the link and choose "Save link as" or the equivalent on your browser menu);
in the case of the faculty member's need to care for a seriously
ill family member, certification of the necessity for and duration
of the faculty member's presence, using the appropriate U.S. Department of Labor form(see the note above about downloading the form before you fill it out);
the title and original signature of an accredited, licensed
or certified medical provider.
When the need for Family and Medical Leave is foreseeable, the application
should be made at least thirty (30) calendar days before the leave is
to begin. When the need is not foreseeable, the application should be
made as soon as practicable.
These materials should be submitted through the Department Chair to
The Dean must sign the form and forward it to the Associate Provost
for Faculty Affairs, 1119 Main Administration Building, for review and
Once approved, copies of FML Parts I and II and the Benefits Office
form are forwarded to the faculty member, Department Chair, Dean, Benefits
Office and Data Services Office. The original material will be kept
in the Office of the Provost.