leave of absence sample forms and letters (00046025-6)

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

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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


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


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.


FMLA/CFRA Designation Letter Conditional Designation

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Attachment Number 5

Form FMLA/CFRA Designation Letter Final Designation

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.



PDL/FMLA Designation Letter


PDL Only Designation Letter


Notice of Family Care and Medical Leave (CFRA Leave) and Pregnancy Disability Leave (Notice B)


California Certification of Health Care Provider

Employees must give this form to their health care providers for completion.


Letter Granting Additional Leave After Expiration of FMLA/CFRA or FMLA/PDL Leave


Letter Regarding Additional Leave After Expiration of FMLA/CFRA Leave Letter to Health Care Provider Regarding Reasonable Accommodation Questionnaire Reasonable Accommodation Questionnaire

Employees must give these documents to their health care providers for completion.

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Attachment Number 12

Form Return-to-Work Certification

Use Use this form when employees are returning to work from FMLA/CFRA, FMLA/PDL or PDL (other than bonding leave).

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.

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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.



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.


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

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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

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.

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.


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


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 empl


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