Rights & Responsibilities Form Mapping
The information below walks through how the fields in the Notice of Eligibility & Rights and Responsibilities form are generated from Leave Manager.
Top Section
| Letter | Location in Leave Manager | Letter | Location in Leave Manager |
|---|---|---|---|
| A | Current Date | M | A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of an impending call or order to covered active duty status. Your family member on covered active duty is your: |
| B | My Profile > Company Name | N | Leave Reason tab --> Select Leave Request Reason --> A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of an impending call or order to covered active duty status. Your family member on covered active duty is your: Spouse |
| C | Employee related to the leave request | O | Leave Reason tab --> Select Leave Request Reason --> A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of an impending call or order to covered active duty status. Your family member on covered active duty is your: Parent |
| D | Eligibility tab --> Date request was submitted: | P | Leave Reason tab --> Select Leave Request Reason --> A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of an impending call or order to covered active duty status. Your family member on covered active duty is your: Child of any age |
| E | First day of scheduled leave for the request | Q | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member who is a covered service member with a serious injury or illness. You are the service member’s: |
| F | Leave Reason tab --> Select Leave Request Reason --> The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or newly-placed child | R | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member who is a covered service member with a serious injury or illness. You are the service member’s: Spouse |
| G | Leave Reason tab --> Select Leave Request Reason --> Your own serious health condition | S | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member who is a covered service member with a serious injury or illness. You are the service member’s: Parent |
| H | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member due to a serious health condition. Your family member is your: | T | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member who is a covered service member with a serious injury or illness. You are the service member’s: Child |
| I | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member due to a serious health condition. Your family member is your: Spouse | U | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member who is a covered service member with a serious injury or illness. You are the service member’s: Next of kin |
| J | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member due to a serious health condition. Your family member is your: Parent | V | Leave Reason tab --> Select Leave Request Reason --> Other |
| K | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member due to a serious health condition. Your family member is your: Child under age 18 | W | Leave Reason tab --> Select Leave Request Reason --> Other <Drop down item> |
| L | Leave Reason tab --> Select Leave Request Reason --> You are needed to care for your family member due to a serious health condition. Your family member is your: Child 18 years or older and incapable of self-care because of a mental or physical disability |
Section I - Notice of Eligibility
| Letter | Location in Leave Manager | Letter | Location in Leave Manager |
|---|---|---|---|
| X | Eligibility tab --> All radios buttons must be set to "Yes" for the sub questions after "Is this employee an airline flight crew member?" | CC | Entitlement tab --> Leave Request --> Employee has not worked 1250 hours prior to this request within the preceding 12-month period = Employee has not met the federal FMLA's 1250 hours of service requirement. As of the first day of requested leave, the employee will have worked approximately [text input box, $HoursTowardsRequirements] towards this requirement. |
| Y | Eligibility tab --> Leave Request --> At least one radio button for the sub questions must be set to "no" after answering "Is this employee an airline flight crew member?" | DD | Eligibility tab --> Leave Request --> Does the employee work at and/or report to a site with 50 or more employees within 75 miles as of the date of the leave request? = no |
| Z | Eligibility tab --> Leave Request --> Not an airline flight crew member, Not worked 12 months. This is only used for employees that answer NO to the airline flight crew member question. | EE |
"Eligibility tab --> IS an airline flight crew member, in Federal Requirements: one of the questions must be ""no"" •Has the employee worked or been paid for at least 60 percent of the applicable total monthly guarantee or the equivalent, for the previous 12-month period? •Has the employee worked or been paid for at least 504 hours (not including personal commute time or time spent on vacation or medical or sick leave) during the previous 12-month period?" |
| AA | Entitlement tab --> Leave Request --> Employee has not worked for this company for at least 12 months = Employee has not met the federal FMLA's 12 month length of service requirement. As of the first day of requested leave, the employee will have worked approximately (user text) months towards this requirement. | FF | Administrative tab --> Part D * Name of Contact for this request: |
| BB | Eligibility tab --> Leave Request --> Not an airline flight crew member, Not worked 1250 hours. This is only used for employees that answer NO to the airline flight crew member question. | GG | Administrative tab --> Part D * Contact Information (e.g., phone, email, location): |
Section II - Additional Information Needed
| Letter | Location in Leave Manager | Letter | Location in Leave Manager |
|---|---|---|---|
| HH | Certification Tab --> Will certification or other information be requested/required? (medical or otherwise): | OO |
Certification Tab --> We request that you provide reasonable documentation or a statement to establish the relationship between you and your family member, including in loco parentis relationships (as explained on page one). The information requested must be returned to us by ____________________ (mm/dd/yyyy). You may choose to provide a simple statement of the relationship or provide documentation such as a child’s birth certificate, a court document, or documents regarding foster care or adoption-related activities. Official documents submitted for this purpose will be returned to you after examination.
OO > NN:Certification Tab --> IF OO - SufficientDocumentation = true, fill in (User's date in OO paragraph) with NN |
| II | Certification Tab --> We request that the leave be supported by a certification: Select one in dropdown: | PP | Certification Tab --> Other information needed (e.g. documentation for military family leave): (checkbox) |
| JJ | Certification Tab --> We request that the leave be supported by a certification, as identified below: Health Care Provider for the Employee | Certification Tab --> Other information needed (e.g. documentation for military family leave): (User's text) | |
| KK | Certification Tab --> We request that the leave be supported by a certification, as identified below: Health Care Provider for the Employee's Family Member | RR |
The information requested must be returned to us by: CHECK if PP Is CHECKED
IF RR = True fill in the date for RR with NN |
| LL | Certification Tab --> We request that the leave be supported by a certification, as identified below: Qualifying Exigency | SS | Administrative tab --> Part D * Name of Contact for this request: |
| MM | Certification Tab --> We request that the leave be supported by a certification, as identified below: Serious Illness or Injury (Military Caregiver Leave) | TT | Administrative tab --> Part D * Contact Information (e.g., phone, email, location): |
| NN | Certification Tab --> If requested, medical certification must be returned by:______(mm/dd/yyyy) (Must allow at least 15 calendar days from the date the employer requested the employee to provide certification, unless it is not feasible despite the employee's diligent, good faith efforts.) |
Section III - Notice of Rights and Responsibilities
| Letter | Location in Leave Manager | Letter | Location in Leave Manager |
|---|---|---|---|
| UU | Set Up FMLA Leave Parameters --> Define your Federal Leave Year for this Location --> Calendar Year | HHH | This checkbox should be checked if III has text to display. |
| VV | Set Up FMLA Leave Parameters --> Define your Federal Leave Year for this Location --> Fixed 12-Month Period | III | Administrative Tab - The applicable conditions for use of paid leave include: |
| WW | Set Up FMLA Leave Parameters --> Define your Federal Leave Year for this Location --> Fixed 12-Month Period | JJJ | "Set Up FMLA Leave Parameters --> For Federal Leave ONLY - Copy of Conditions --> Is a copy of conditions applicable to sick, vacation, or other leave usage available? |
| XX | Set Up FMLA Leave Parameters --> Define your Federal Leave Year for this Location --> 12-Month Measured Forward | KKK | "Set Up FMLA Leave Parameters --> For Federal Leave ONLY - Copy of Conditions --> The copy of conditions is referred to as: |
| YY | Set Up FMLA Leave Parameters --> Define your Federal Leave Year for this Location --> 12-Month Rolling Backward | LLL | "Set Up FMLA Leave Parameters --> For Federal Leave ONLY - Copy of Conditions --> Please describe where/how employees can access a copy of conditions: |
| ZZ | If FMLA.LeaveRequestReason[LeaveReasonId] = 6 = TRUE THEN (If applicable,) the single 12-month period for Military Caregiver Leave started on _______(mm/dd/yyyy). | MMM | Administrative Tab --> C. *Name of contact person for employee health benefits questions: |
| AAA |
Administrative Tab --> Administrative Info --> The employee IS considered a key employee. OR Administrative Tab --> Administrative Info --> The employee IS NOT considered a key employee. |
NNN | Administrative Tab --> C. * Contact Information (e.g., phone, email, location): |
| BBB |
Administrative Tab --> Administrative Info --> The employee IS considered a key employee = true and We HAVE determined that the employee will be reinstated = true OR Administrative Tab --> Administrative Info --> The employee IS considered a key employee = true and We HAVE NOT determined that restoring the employee to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to us. |
OOO | Administrative Tab --> Minimum Grace Period Before Cancellation (30 days or longer): |
| CCC | Administrative Tab --> Some or all of your FMLA leave will not be paid. Any unpaid FMLA leave taken will be designated as FMLA leave and counted against the amount of FMLA leave you have available to use in the applicable 12-month period. (checkbox) | PPP | Administrative tab --> Part D * Name of Contact for this request: |
| DDD | Administrative Tab --> You have requested to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of FMLA leave you have available to use in the applicable 12-month period. (checkbox) | QQQ | Administrative tab --> Part D * Contact Information (e.g., phone, email, location): |
| EEE | Administrative Tab --> We are requiring you to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of FMLA leave you have available to use in the applicable 12-month period. (checkbox) | RRR | Administrative Tab -> While on leave, the employee will be / will not be required to furnish periodic reports of their status and intent to return to work? (WILL BE) |
| FFF | Administrative Tab --> Other: (e.g., short-or long-term disability, workers’ compensation, state medical leave law, etc.) (checkbox) | SSS | Administrative Tab -> While on leave, the employee will be / will not be required to furnish periodic reports of their status and intent to return to work? (WILL NOT BE) |
| GGG | Administrative Tab --> Other: (e.g., short-or long-term disability, workers’ compensation, state medical leave law, etc.) (User text) | TTT | Administrative Tab -> While on leave, the employee will be / will not be required to furnish periodic reports of their status and intent to return to work? (WILL BE) - > Text Box |