University of Illinois FMLA Usage Report
For Departmental Use Only
Entitlement Period Date FML begins {mm/dd/year} – Twelve Months from Beginning Date {mm/dd/year}
*Example:  (10/14/2002 – 10/13/2003)

When the employee returns from the FMLA leave, please send a copy of this form to the appropriate campus Human Resources office.  

Date:  ____/____/ 200__
Employee Name:  _______________________________
		           (Last, First, and MI)
UIN:  __________________  Department Code: _______
Department Name:  ______________________________
Department Contact:  _____________________________
Contact Phone Number:  __________________________

Beginning Date of Leave:

____/____/200__

Ending Date of Leave:

____/____/200__

Type of Leave

    Block of Time     Intermittent     Reduced Schedule

Reason for Leave

    Employee Illness     Family Illness     Birth/Adoption

**Total number of hours available to the employee is calculated as follows: 12 weeks *  the number of hours in the employee’s workweek less any used FMLA leave. 

Pay Period	Pay Period Dates	FMLA Paid as Parental Leave	FMLA Paid as Sick Leave	FMLA Paid as Vacation	FMLA Unpaid	Total FMLA Hours/Days Charged	FMLA Balance Remaining	

							**	

								

								

								

*Please note that holidays are counted as FMLA when leave is counted as a block of time. Floating holidays that are used to remain in pay status are counted as part of the 12-week FMLA entitlement.

University of Illinois FMLA Usage Report 
Entitlement Period mm/dd/year –mm/dd/year

					
Pay Period	Pay Period Dates	FMLA Paid as Parental Leave	FMLA Paid as Sick Leave	FMLA Paid as Vacation	FMLA Unpaid	Total FMLA Hours/Days Charged	FMLA Balance Remaining	

							**	

								

								

								

								
*Please note that holidays are counted as FMLA when leave is counted as a block of time. Floating holidays that are used to remain in pay status are counted as part of the 12-week FMLA entitlement.

Returned to Work on:  _____/____/200__
Comments:_______________________________________________________________________________________________________

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