Leave of Absence Sample Forms and Letters (00046025-6)

Download Leave of Absence Sample Forms and Letters (00046025-6)

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<p>OVERVIEW OF LEAVE OF ABSENCE FORMS Below is a list of the sample forms included in this packet. These forms may be used by your organization when processing employee requests for leave under the Family and Medical Leave Act (FMLA), the California Family Rights Act (CFRA) and/or the California Pregnancy Disability Leave (PDL) law. This packet also contains documents related to the reasonable accommodation process. This packet does not include sample FMLA, CFRA, and PDL policies. If you would like a sample of one or all of these policies for use by your organization, or would like us to review your existing policies for legal compliance, please contact Jennifer Brown Shaw at (916) 3265150. Please note: This packet is intended as a general resource and reference tool for employers who are subject to the FMLA/CFRA. The forms in this packet do not cover every aspect of FMLA/CFRA administration. Nor do they anticipate every circumstance that may arise during the administration process. You should consult with competent legal counsel for guidance on specific issues.Attachment Number 1 Form Leave of Absence Checklist Use Use this checklist when processing employee leaves of absence under your organizations FMLA/CFRA/PDL policies. Employees complete this form when requesting a leave of absence under FMLA/CFRA/PDL. Notes</p> <p>2</p> <p>Request for Leave Under the Family and Medical Leave Act and/or California Family Rights Act and/or Pregnancy Disability Leave Law Letter Denying FMLA/CFRA, FMLA/PDL and/or PDL Leave</p> <p>3</p> <p>Use this letter when an employee does not qualify or is otherwise ineligible for FMLA/CFRA/PDL. Use this letter to conditionally designate FMLA/CFRA leave until employee provides medical certification.</p> <p>4</p> <p>FMLA/CFRA Designation Letter Conditional Designation</p> <p>Page 1 of 3 Shaw Valenza LLP 200846025.6.99999.002</p> <p>Attachment Number 5</p> <p>Form FMLA/CFRA Designation Letter Final Designation</p> <p>Use Use this letter to designate FMLA/CFRA leave after receiving the employees medical certification or when a medical certification is not required, such as for bonding leave. Use this letter when an employee qualifies for FMLA/PDL. Use this letter when an employee qualifies for PDL but is not eligible for FMLA/CFRA. Give Notice B to pregnant employees when you first learn of the pregnancy. This may be before the employee requests any time off. (This notice must be provided even if the employee is not eligible for FMLA/CFRA leave.) Give this form to employees who are eligible for FMLA/CFRA/PDL, except where bonding leave is requested. Use this letter when you are approving an extension of FMLA/CFRA or FMLA/PDL without requiring additional medical documentation. Send this packet to employees who have exhausted FMLA/CFRA leave and are requesting additional time off. Use this letter instead of Attachment 11 when you require additional medical documentation before approving the extension of leave.</p> <p>Notes</p> <p>6</p> <p>PDL/FMLA Designation Letter</p> <p>7</p> <p>PDL Only Designation Letter</p> <p>8</p> <p>Notice of Family Care and Medical Leave (CFRA Leave) and Pregnancy Disability Leave (Notice B)</p> <p>9</p> <p>California Certification of Health Care Provider</p> <p>Employees must give this form to their health care providers for completion.</p> <p>10</p> <p>Letter Granting Additional Leave After Expiration of FMLA/CFRA or FMLA/PDL Leave</p> <p>11</p> <p>Letter Regarding Additional Leave After Expiration of FMLA/CFRA Leave Letter to Health Care Provider Regarding Reasonable Accommodation Questionnaire Reasonable Accommodation Questionnaire</p> <p>Employees must give these documents to their health care providers for completion.</p> <p>Page 2 of 3 Shaw Valenza LLP 200846025.6.99999.002</p> <p>Attachment Number 12</p> <p>Form Return-to-Work Certification</p> <p>Use Use this form when employees are returning to work from FMLA/CFRA, FMLA/PDL or PDL (other than bonding leave).</p> <p>Notes We recommend requiring that all employees submit completed return-towork certifications before returning to work. The form should be provided to employees with the other leave paperwork. The health care provider may decide to use his/her own form instead. This is fine so long as it is clear the employee is released to return to work, and any restrictions on the employees ability to perform the essential functions of the job are clearly described.</p> <p>Page 3 of 3 Shaw Valenza LLP 200846025.6.99999.002</p> <p>ATTACHMENT 1LEAVE OF ABSENCE CHECKLIST (For California Employers) **DO NOT DISTRIBUTE TO EMPLOYEES**</p> <p>1.</p> <p>EMPLOYEE ELIGIBILITY FOR FMLA/CFRA Determine if the employee is eligible for FMLA/CFRA leave. An employee is eligible if all the following conditions are met: The employee has been employed for 12 months. The 12 months need not be consecutive, and include periods of leave (e.g., sick, vacation) during which benefits or compensation are provided. The employee has physically worked at least 1250 hours within the last 12 months. Only actual hours physically worked are counted towards the 1,250 hours threshold. The employee works at a workplace with 50 or more employees within 75 miles of the workplace.</p> <p>2.</p> <p>EMPLOYEE ELIGIBILITY FOR PREGNANCY DISABILITY LEAVE</p> <p>All female employees are eligible for PDL. There is no length of service or hours requirement like there is for FMLA/CFRA. If an employee is eligible for FMLA/CFRA, then PDL and FMLA run concurrently. However, PDL and CFRA leave do not generally run concurrently because pregnancy is not defined as a serious health condition under the CFRA. That means that an employee eligible for CFRA normally will have additional leave available to care for the newborn or for other covered purposes when her pregnancy disability ends.</p> <p>3.</p> <p>REASONS FOR FMLA/CFRA LEAVE Determine if the employee has a qualifying reason for FMLA/CFRA leave. The following reasons are covered under FMLA/CFRA: The employees own serious health condition, which renders the employee unable to perform an essential function of the employees position. The birth of a son or daughter and to care for such son or daughter; the placement of a son or daughter with the employee for adoption or foster care and to care for the newly placed son or daughter. A leave for these reasons must be completed within the 12-month period beginning on the date</p> <p>Page 1 of 7 Shaw Valenza LLP 200846025.6.99999.002</p> <p>of birth or placement. In addition, spouses employed by the organization who request leave for this reason may only take a combined total of 12 weeks of FMLA/CFRA leave during any 12-month period.1</p> <p>To care for a spouse, registered domestic partner, son, daughter, son/daughter of a registered domestic partner, or parent (covered relation) with a serious health condition. Because leave to care for a registered domestic partner with a serious health condition is not required under the FMLA, employers should be aware that leave taken for that purpose likely will not count toward any FMLA entitlement. Employers confronted with a situation in which an employee takes CFRA leave to care for a registered domestic partner and subsequently seeks to take FMLA/CFRA leave within the same 12-month period for a different reason should consult with counsel. To care for a spouse, son, daughter, or next of kin (nearest blood relative) who has suffered a serious injury or illness as a result of service in the Armed Forces. Leave taken to care for an injured or ill servicemember is only covered under the FMLA. The FMLA provides for up to 26 weeks of leave to care for a servicemember. The law is currently unclear as to whether this leave is only available during a single 12-month period, or whether an individual can take leave for this purpose in reoccurring 12-month periods. Employers should note that this type of leave is not covered under the CFRA, and leave taken for this reason will not count toward an employees CFRA leave entitlement. Because of a qualifying exigency resulting from a spouse, son, daughter, or parent who is on active duty, or has been called into active duty in the Armed Forces in support of a contingency operation. Leave taken because of a qualifying exigency is only covered under the FMLA. Employers should note that this type of leave is not covered under the CFRA and leave taken for this reason will not count toward an employees CFRA leave entitlement.</p> <p>It is the employers responsibility to designate leave as FMLA and/or CFRA based on information provided by the employee or an employees spokesperson (e.g., spouse, registered domestic partner, parent or health care provider if the employee is incapacitated). In limited circumstances, the employer may designate leave as FMLA/CFRA leave after an employee has already returned to work (e.g., if the employee failed to give the required medical certification). The employer may not inquire about the nature of the employee's or family members' medical condition. The only exception to this is to inquire about whether an employee is suffering from a pregnancy-related condition so the employer can provide PDL to the employee.</p> <p>1</p> <p>CFRA regulations also provide that an employer may (but is not required to) allow an employee to use CFRA leave prior to the birth of a child if the employee has used four months of PDL prior to the birth and the employees health care provider determines that a continuation of the leave is medically necessary. Doing so would not require the employer to provide more than the amount of CFRA leave to which the employee was otherwise entitled. Page 2 of 7 Shaw Valenza LLP 200846025.6.99999.002</p> <p>4.</p> <p>HOW MUCH LEAVE IS AN EMPLOYEE ENTITLED TO UNDER FMLA/CFRA AND PDL? Calculating the amount of FMLA/CFRA leave to which the employee is entitled depends on the method used by the employer. Employees are entitled to 12 weeks of FMLA/CFRA leave within a 12-month period (up to 26 weeks if the employee is taking leave to care for an injured or ill servicemember). Employers can measure the leave year by following any of these four options: (1) the calendar year, (2) any fixed 12-month leave year, such as the fiscal year or the employees hire date, (3) a 12-month period measured forward from the date the employees first FMLA/CFRA leave begins, or (4) a rolling 12-month period measured backward from the date an employee uses any FMLA/CFRA leave. Employers must choose one option and use it consistently.</p> <p>An eligible employee may receive PDL of up to four months (88 workdays for full-time employees). Part-time employees receive four months at their regular schedule. The amount of time taken is limited to the employees actual period of disability. For most pregnancies, employees are considered disabled for a few weeks prior to the birth and between six and eight weeks after delivery. Of course, there are exceptions. Following PDL, the employee may be eligible for any remaining FMLA leave and for up to 12 additional weeks of CFRA leave. (PDL does not run concurrently with CFRA leave.)</p> <p>5.</p> <p>REQUEST FOR FMLA/CFRA/PDL </p> <p>The employee must give the employer at least 30 days notice of the need for leave (if the need for leave is foreseeable). Verbal notice is acceptable. If timely notice is not given, the employer should determine the reason for the delay before denying leave. An employees failure to provide reasonable notice may be grounds for delay of leave. However, in emergency situations, employees may be unable to give the full 30 days notice. An employer should carefully consider the circumstances before denying leave for this reason.</p> <p>6.</p> <p>DESIGNATION OF FMLA/CFRA/PDL Once an employer is on notice that an employee requires time off for a purpose covered by FMLA/CFRA, the employer must designate the time off as FMLA/CFRA within two business days. If the employer does not have adequate documentation to establish the employee or the employees covered family relation has a serious health condition, then the employer should send the employee a letter conditionally designating the leave as FMLA/CFRA leave contingent on receiving the proper medical certification. Failure to give this notice may prevent the employer from counting the leave toward the employees annual FMLA/CFRA leave entitlement.</p> <p>If an employee is on leave for a pregnancy-related medical condition, the employee must receive notice that the time off is covered both by PDL and FMLA and that the FMLA and PDL leaves are running concurrently (assuming the FMLA eligibility requirements are met). Even ifPage 3 of 7 Shaw Valenza LLP 200846025.6.99999.002</p> <p>the leave does not qualify as an FMLA leave, the employer should give the employee written notice that the leave is being counted as PDL. For employees who are eligible for PDL only, the employer must respond to the leave request as soon as practicable, but in no event later than 10 calendar days after the employee makes the request. If an employee takes PDL (see below) and wishes to take bonding leave after her disability has ended, then the employee must be informed that the additional leave counts as a CFRA leave and she is entitled to up to 12 weeks of CFRA leave. Note: the employee is entitled to a maximum of 12 weeks; if she used CFRA leave for another reason in the prior 12-month period, she will be entitled only to the remainder of the original 12 weeks.</p> <p>7.</p> <p>MEDICAL CERTIFICATIONS FOR LEAVES TAKEN BECAUSE OF A SERIOUS HEALTH CONDITION, INCLUDING PREGNANCY DISABILITY At the time FMLA/CFRA/PDL is requested, the employer must provide the employee with notice of the requirement that the employee furnish medical certification of a serious health condition within 15 calendar days of the employers request, unless impracticable. The 15-day certification requirement does not apply to employees seeking PDL leave; certification for PDL may be provided at any time prior to starting the leave. The employer should review the medical certification form signed by the health care provider and determine if further clarification is needed. If further clarification is necessary, a health care provider representing the employer may contact the employees health care provider, with the employees permission, to clarify and confirm the information provided by the health care provider, but may not seek additional information. The employer may seek a second medical opinion regarding the employees own health condition (not the condition of a covered relation) if there is a reason to doubt the validity of the certification provided by the employee. If the second opinion is inconsistent with the first, then the employer can request a third, binding opinion, which must be offered by a mutually-agreeable health care provider and paid for by the employer. A PDL certification from the health care provider must contain: (1) the date on which the woman became disabled due to pregnancy, (2) the probable duration of the period or periods of disability, and (3) an explanatory statement that, due to the disability, the employee is unabl...</p>


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