{"id":191872,"date":"2025-06-12T09:05:12","date_gmt":"2025-06-12T13:05:12","guid":{"rendered":"https:\/\/www.rochester.edu\/human-resources\/?page_id=191872"},"modified":"2025-10-17T17:18:03","modified_gmt":"2025-10-17T21:18:03","slug":"fmla-pay-change-request","status":"publish","type":"page","link":"https:\/\/www.rochester.edu\/human-resources\/benefits\/leave-disability\/fmla-pay-change-request\/","title":{"rendered":"FMLA Supplemental Pay \u2013 Change Request Form for Union Employees"},"content":{"rendered":"<p><em><strong>This form is for SEIU\/1199 union members (BU2\/BU4) only.<\/strong><\/em><\/p>\n<p>Complete this form if you have taken FMLA related absence(s) and would like to use your accrued PTO\/Sick time to supplement it. This form is not needed if you have exhausted your PTO\/Sick time. Your accrued vacation time will be used automatically. <strong><u>Only past dates will be accepted<\/u>. Future dates are ineligible and will not be permitted.<\/strong><\/p>\n<p><a class=\"button button--blue\" href=\"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2025\/10\/fmla-supplemental-pay-change-request-union.pdf\">Printer-friendly version of the FMLA Supplemental Pay \u2013 Change Request Form for Union Employees<\/a><\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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action='\/human-resources\/wp-json\/wp\/v2\/pages\/191872' data-formid='422' novalidate>\n<div class='gform-body gform_body'>\n<div id='gform_fields_422' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<fieldset id=\"field_422_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf-name form-control-icon-complex\"  data-field-class=\"gf-name form-control-icon-complex\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Name as listed in myURHR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_422_1'>\n<p>        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id='input_422_5' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div>\n<\/div>\n<div id=\"field_422_6\" class=\"gfield gfield--type-post_title gfield--input-type-post_title gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_422_6'>Department name<\/label><\/p>\n<div class='ginput_container ginput_container_post_title'>\n\t\t\t\t\t<input name='input_6' id='input_422_6' type='text' value='' class='large'    aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div>\n<\/div>\n<fieldset id=\"field_422_7\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf-name form-control-icon-complex\"  data-field-class=\"gf-name form-control-icon-complex\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Manager name<\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_422_7'>\n<p>                            <span id='input_422_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_7.3' id='input_422_7_3' value=''   aria-required='false'     \/><br \/>\n                                                    <label for='input_422_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label><br \/>\n                                                <\/span><\/p>\n<p>                            <span id='input_422_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_7.6' id='input_422_7_6' value=''   aria-required='false'     \/><br \/>\n                                                    <label for='input_422_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<\/fieldset>\n<div id=\"field_422_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_422_12'>Date(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_12' id='input_422_12' type='text' value='' class='large'  aria-describedby=\"gfield_description_422_12\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<div class='gfield_description' id='gfield_description_422_12'>Please list the FMLA dates (MM\/DD\/YYYY) you have already taken. Only past dates will be accepted. Future dates are ineligible and will not be permitted.<\/div>\n<\/div>\n<div id=\"field_422_10\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Employee Acknowledgment<\/p>\n<p>By signing below, I understand the information provided and acknowledge that my accrued leave balances will be adjusted accordingly. I authorize the use of my accrued PTO\/sick time for my FMLA absence(s) taken as noted above. 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