School of Medicine Office of Faculty Affairs

Administrative Checklists: Faculty Medical & Family Leave (FMFL)

1. Completed Employee Record (ER)
2. Faculty member’s written request, stating type of leave (family leave or medical leave) and requested time period
3. Letter of approval from department chairman to contain:

    a. Endorsement
    b. Assurance of coverage for duties

4. Completed “Certification of Physician or Practitioner Form” (for Medical Leave)

5. Service Request (if past payroll deadline)

THE COMPLETED EMPLOYEE RECORD (ER) MUST BE SUBMITTED WITH ORIGINAL AND ONE COPY OF ALL SUPPORTING DOCUMENTATION