Family and Medical Leave Act (FMLA) Request

Pursuant to the Family and Medical Leave Act (FMLA) Goucher offers leave options to its employees who need to take time off for serious health conditions (for themselves, family members and covered service members); birth, adoption, or foster care placement of a child; and military exigency. For details about your rights under FMLA please consult the links on this page to the college’s FMLA policy and forms.

How to request FMLA leave on-line

You are in Step 1 of the FMLA process (request and eligibility determination). Please complete the information below to submit your request for leave. Our FMLA Coordinator will review your information and determine whether or not you are eligible for FMLA. Eligibility is dependent upon an employee having worked 1,250 hours in the last 12 months and having been employed at Goucher for at least one year. You will receive your eligibility determination within five business days, unless extenuating circumstances delay this determination. In addition to completing this formal request process, you are also responsible for notifying your supervisor about the dates of the anticipated absence so that appropriate arrangements can be made regarding scheduling, office coverage, etc. Please note that you are not obligated to disclose private medical information and/or the reason for leave to your supervisor.

If you are eligible for FMLA you will move to Step 2 of the FMLA application process, in which you submit the required certification supporting the need for the leave, including documentation from a medical provider, if required. The college will then grant or deny the leave and will inform you of the decision.

If you have any questions about FMLA, Goucher’s leave policies or this form, please contact the Office of Human Resources, hr@goucher.edu or 410-337-6135.

Completing this form will also serve as your request for Medical Non-FMLA (if you do not qualify for FMLA). Non-FMLA medical leave may not provide job protection, however.

NOTE – you are not required to submit an application electronically, and may make an appointment with the Office of Human Resources if you prefer.

IMPORTANT - If your need for family/medical leave is foreseeable (such as birth, adoption, foster care placement, planned medical treatment or caring for a covered service member), you must give the Office of Human Resources 30 days' prior written notice. If this is not possible, and, in cases of leave due to a qualifying exigency related to covered active duty or call to covered active duty, you must give notice as soon as practicable and explain why providing noctice was not practicable. Failure to provide such notice and/or explanation for failure to provide 30 days’ notice may be grounds for delay or denial of leave. Where the need for leave is not foreseeable, you are expected to notify the Office of Human Resources within one to two business days of learning of your need for leave, except in extraordinary circumstances.

FMLA Leave Request form

If you see this don't fill out this input box.

First name *

Last name *

Goucher email address *

Goucher phone number *

I am requesting FMLA leave for the following reasons: *

the birth of a son or daughter and in order to care for such son or daughter;

the placement of a son or daughter with you for adoption or foster care and in order to care for such son or daughter;

to care for a spouse, domestic partner, son, daughter, or parent with a “serious health condition";

because of your own “serious health condition” which renders you unable to perform one of the essential functions of your position; or

because of any qualifying exigency arising out of the fact that your spouse, domestic partner, son, daughter, or parent is a military member on covered active duty status or call to covered active duty status (or has been notified of an impending call or order to covered active duty) in the Armed Forces. Note that a call to covered active duty for purposes of leave taken because of a qualifying exigency refers to a Federal call to active duty. State calls to active duty are covered in limited circumstances – check with HR if you have a question.

I will need leave beginning on: *

I would like to: *

Make an appointment with the Office of Human Resources to discuss my application and receive certification documents in person.

Receive a response from the Office of Human Resources electronically, together with copies of documents that I need to complete.

Additional Information

Non-disclosure of Genetic Information

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, Goucher will ask physicians to exclude any genetic information when responding to requests for medical information as part of FMLA. `Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Reporting while on leave

If you take leave because of your own serious health condition, to care for an eligible family member with a serious health condition, to care for a covered service member, or because of a qualifying exigency, you must contact the Office of Human Resources each month regarding the status of the health condition or qualifying exigency and your intention to return to work.

Use of Available Leave for Family/Medical Leave*

If you request leave due to your own serious health condition, for the birth of a child, for the placement of a child with you for adoption or foster care, or to care for an eligible family member or covered service member with a serious health condition, Goucher requires you to use your available sick and/or vacation leave (for which you will be paid). The remaining portion of your family/medical leave is unpaid.

If you request family/medical leave because of a qualifying exigency arising out of the fact that your spouse, domestic partner, son, daughter, or parent is a military member on covered active duty status or call to covered active duty status (or has been notified of an impending call or order to covered active duty) in the Armed Forces, Goucher requires you to use available vacation leave (for which you will be paid).

The substitution of paid leave time for unpaid leave time does not extend the 12-week or 26- week leave period.

*Faculty and Instructional Staff: please refer to Faculty Leave Policy

Medical Benefits and Retirement Plan Benefits While On Leave

During an approved family/medical leave, Goucher will maintain your existing Goucher health benefits (if applicable). If paid leave is substituted for unpaid family/medical leave, the College will deduct your portion of the health plan premium as a regular payroll deduction. If a portion of your leave is unpaid, you must remit your portion of the health plan premium on a monthly basis to the Office of Human Resources by the first of each month. If your premium payment is more than 30 days late, your health insurance may be canceled, or at Goucher’s option, Goucher may pay your share of the premiums during your family/medical leave, and deduct these payments from your paycheck when you return to work. If your health coverage is discontinued, it will be restored when you return to work.

If you elect not to return to work at the end of the leave period, you will be required to reimburse Goucher for the cost of the premiums paid by Goucher for providing coverage during your leave, unless you cannot return to work because of your own serious health condition, or a serious health condition of an eligible family member or a covered service member, or other circumstances beyond your control.

During an approved family/medical leave, Goucher will continue to make the usual employer contributions on the basis of salary paid and to deduct from your salary the employee contribution to your retirement plan on the basis of salary paid, for employees who receive this benefit.

Returning from Leave

If you take leave because of your own serious health condition, you are required to provide medical certification that you are fit to resume work. Employees failing to provide the required certification will not be permitted to resume work until it is provided. Employees taking intermittent leave are generally not required to obtain such certification.

FMLA Forms

You may download copies of the FMLA Policy, Certification forms, and Employee Rights & Responsibilities PDFs on the Family & Medical Leave Act policy page.