Benefits

Voluntary Shared Leave Donation Purpose: Use this form to make a donation to the Voluntary Shared Leave (VSL) program. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

Short Term Disability Benefits Request (Form 701) Purpose: Use this form to request short-term benefits through the Disability Income Plan of North Carolina. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

Short Term Disability Benefits Earnings and Medical Eligibility Report (Form 703) Purpose: Use this form to report monthly certification from the medical provider for short term disability benefits. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

Prior Creditable State Service Verification Request (included with new hire forms) Purpose: Use this form to request verification of creditable prior State service. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

Paid Parental Leave Request Purpose: Use this form to request eligibility for participation in the Paid Parental Leave (PPL) program. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

Optional Retirement Program Acknowledgement (ORP-3) (Please reference the forms section under the “Optional Retirement Program Information” and click on the OTP-3 acknowledgement with instructions. Purpose: Use this form to acknowledge participation in the Optional Retirement Plan (ORP) at the time of employee separation. Email Contact: benefits@charlotte.edu Last Updated: August 15, 2024

Short Term Disability – Medical Report for Eligibility Review (Form 7A) Purpose: Use this form to request medical eligibility for short-term disability coverage under the Disability Income Plan of North Carolina. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

FMLA Request (9 Month) Purpose: Use this form to request authorization for extended leave under the Family Medical Leave Act (FMLA) – 9 month employees. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

FMLA Request (12 Month) Purpose: Use this form to request authorization for extended leave under the Family Medical Leave Act (FMLA) – 12 month employees. Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024

Fitness for Duty Certification Purpose: Use this form to provide verification of ‘fitness for duty’ when an employee has received medical authorization to return to work (with or without work restrictions). Email Contact: benefits@charlotte.edu Last Updated: August 14, 2024