[
]
[Non-FMLA Unpaid Medical Leave Exhaustion and
following status letter]
[Use applicable wording options according to employee’s situation. Delete the title and this statement and
replace all bracketed/highlighted wording in the letter.]
[Date]
[Employee Name]
[Address]
Dear [Name]:
I am writing to advise that your current unpaid medical leave of absence will be exhausted [Month, Day,
Year] and as a reminder, you have exhausted your paid leave accruals and [Choose one: have exhausted
your Family Medical Leave OR are not eligible for Family Medical Leave] this calendar year. I hope your
condition has improved to the required level for you to return to work with or without reasonable
accommodation by or before the above date.
If you are seeking to return to work, please share this letter and release to work form with your treating
healthcare provider. Your treating healthcare provider must complete and submit the following
requested information for consideration in return to work planning. This release to work must be
received by my office no later than [5 days prior to the end of the current leave of absence], and must
include verification of your ability to perform the essential functions of your position or necessary
medical restrictions. We are willing to provide a reasonable accommodation if necessary for you to
perform the essential functions of your job. Enclosed is a copy of the [Essential and Marginal Job
Function Analysis or job description] of your position to review with your treating healthcare provider in
determining applicable and necessary medical restrictions. This document provides your position
requirements and expectations.
If you are seeking to return to work and your health condition will not permit you to perform the
essential functions of your position, you may request another unpaid leave of absence. For
consideration of unpaid medical leave, your treating health provider must complete the attached nonFMLA continuous leave form and return it to my office no later than 5 days prior to the exhaustion of
your current leave of absence. We will use the information provided to determine if another leave of
absence may be reasonable. Please immediately contact UI Benefits to discuss insurance coverage
during an approved unpaid leave.
If you are not seeking to return in the future , please contact me to make arrangements for you to pick
up any personal property in the department, return any University property (ID card, Parking Tag and/or
card, departmental parking placard, uniforms, work keys, procurement card, etc.), and to provide
written documentation of your decision. If you are not returning to work we must end your University
employment on the last date of your medical leave of absence.
Please be aware that ending your employment with The University of Iowa will not impact your Long
Term Disability application.Please contact University Benefits, 120-40 USB (335-2676), to discuss
retirement funds, life insurance, and health, dental, vision, and hearing insurance options. If you have
unused accrued vacation, the financial amount of this accrual will be paid to you approximately one
month after the last day of your medical leave of absence.
Although you may not be seeking employment at this time, please contact jobs.uiowa.edu for
information regarding employment opportunities, rights, and responsibilities that you may be interested
in and eligible for in the future.
Please contact me with any questions.
Sincerely,
[HR Unit Representative]
[Title]
Attachments: Release to Work Form
Essential and Marginal Job Function Analysis or Job Description
cc: [Supervisor]
Faculty Staff Disability Services
Enclosure: Essential/Marginal Job Function Analysis
AND
Release to Return to Work Document
OR
Non-FMLA Continuous Leave Request
[Copyright The University of Iowa 2012. All rights reserved.
Last Updated March 2012]