Forms

FMLA and VESSA Information for Employees

FMLA Form and Instructions

Please read carefully the Employee Rights and Responsibilities section before completing the FMLA form. A University of Illinois employee should complete the FMLA application section of the form (except in cases where the employee is incapacitated). The employee’s Health Care Provider should complete the FMLA Medical Certification section of the form.

FMLA Form in PDF Format which requires Adobe Acrobat Reader

FMLA Form in Rich Text Format (RTF) for download

For Employee's Serious Health Condition: Acrobat format | Rich text format
For Family Member's Serious Health Condition: Acrobat format | Rich text format
For Serious Injury or Illness of Covered Servicemember: Acrobat format | Rich text format

VESSA Form and Instructions

Please read carefully the Employee Rights and Responsibilities section before completing the VESSA form. A University of Illinois employee should complete the VESSA application (except in cases where the employee is incapacitated). If medical certification is required, the employee's Health Care Provider should complete the FMLA Medical Certification form.

VESSA Form in PDF Format which requires Adobe Acrobat Reader

VESSA Form in Rich Text Format (RTF) for download

For Employee's Serious Health Condition: Acrobat format | Rich text format
For Family Member's Serious Health Condition: Acrobat format | Rich text format
For Serious Injury or Illness of Covered Servicemember: Acrobat format | Rich text format

The University of Illinois is an Affirmative Action/Equal Opportunity employer

Copyright © 2009 University of Illinois at Urbana-Champaign
Maintained by the Staff Human Resources
Mark Overmier................... zorkahn@illinois.edu
Last Update: 05/05/2009