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
Form
Use
1
Leave of Absence Checklist
Use this checklist when
processing employee leaves
of absence under your
organization’s
FMLA/CFRA/PDL policies.
2
Request for Leave Under the
Family and Medical Leave Act
and/or
California Family Rights Act
and/or Pregnancy Disability
Leave Law
Employees complete this
form when requesting a leave
of absence under
FMLA/CFRA/PDL.
3
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.
4
FMLA/CFRA Designation Letter
– Conditional Designation
Use this letter to conditionally
designate FMLA/CFRA leave
until employee provides
medical certification.
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Notes
Attachment
Number
Form
Use
5
FMLA/CFRA Designation Letter
– Final Designation
Use this letter to designate
FMLA/CFRA leave after
receiving the employee’s
medical certification or when
a medical certification is not
required, such as for
“bonding” leave.
6
PDL/FMLA Designation Letter
Use this letter when an
employee qualifies for
FMLA/PDL.
7
PDL Only Designation Letter
Use this letter when an
employee qualifies for PDL
but is not eligible for
FMLA/CFRA.
8
Notice of Family Care and
Medical Leave (CFRA Leave)
and Pregnancy Disability Leave
(“Notice B”)
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.)
9
California Certification of Health
Care Provider
Give this form to employees
who are eligible for
FMLA/CFRA/PDL, except
where “bonding” leave is
requested.
10
Letter Granting Additional
Leave After Expiration of
FMLA/CFRA or FMLA/PDL
Leave
Use this letter when you are
approving an extension of
FMLA/CFRA or FMLA/PDL
without requiring additional
medical documentation.
11
Letter Regarding Additional
Leave After Expiration of
FMLA/CFRA Leave
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.
Letter to Health Care Provider
Regarding Reasonable
Accommodation Questionnaire
Reasonable Accommodation
Questionnaire
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Notes
Employees must give
this form to their health
care providers for
completion.
Employees must give
these documents to
their health care
providers for
completion.
Attachment
Number
12
Form
Use
Notes
Return-to-Work Certification
Use this form when
employees are returning to
work from FMLA/CFRA,
FMLA/PDL or PDL (other
than “bonding” leave).
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
employee’s ability to
perform the essential
functions of the job are
clearly described.
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ATTACHMENT 1
LEAVE OF ABSENCE CHECKLIST
(For California Employers)
**DO NOT DISTRIBUTE TO EMPLOYEES**
1.
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:
2.

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.
EMPLOYEE ELIGIBILITY FOR PREGNANCY DISABILITY LEAVE
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.
3.
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 employee’s own serious health condition, which renders the
employee unable to perform an essential function of the employee’s
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 employee’s 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 employee’s CFRA
leave entitlement.
It is the employer’s responsibility to designate leave as FMLA and/or CFRA based on
information provided by the employee or an employee’s 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.
1
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 employee’s 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.
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4.
5.
6.
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 employee’s
hire date, (3) a 12-month period measured forward from the date the employee’s 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.

An eligible employee may receive PDL of up to four months (88 workdays for fulltime employees). Part-time employees receive four months at their regular
schedule. The amount of time taken is limited to the employee’s 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.)
REQUEST FOR FMLA/CFRA/PDL

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 employee’s 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.
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
employee’s “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 employee’s annual FMLA/CFRA leave entitlement.
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 if
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.
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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.
7.
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
employer’s 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 employee’s health care provider, with the employee’s 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 employee’s 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 unable to work at all or is unable to perform any one or
more of the essential functions of her position without undue risk to herself, the
successful completion of her pregnancy or to other persons.

Determine if medical recertification will be needed. Calendar a date, at least 15
days before the leave of absence expires, to notify the employee that further
certification will be required if the employee needs to extend the leave of absence
beyond the date stated in the original certification. There are other circumstances
when recertification may be appropriate. Please consult legal counsel for additional
information.
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8.
INTERMITTENT LEAVE AND REDUCED SCHEDULES
Determine if the employee is entitled to take intermittent and/or reduced schedule leave.
Such leaves are provided when:
9.
10.

It is medically necessary, including due to a pregnancy-related
condition. If so, the employee is entitled to take leave intermittently or on a
reduced leave schedule.
Determine an appropriate schedule for the
employee.

It is requested for the birth or placement of a child in foster care or
adoption. The employer may require the employee to take intermittent leave
in segments of at least two weeks, except that the employer must grant a
request for leave of less than two week’s duration on two occasions.

The employer generally may make deductions from an exempt employee’s salary for
time taken as intermittent or reduced schedule leave within a workweek without
affecting the exempt status of the employee, so long as the leave qualifies under the
federal FMLA. However, employers should not do this without consulting counsel.

Determine if the employee should be temporarily transferred.

For employees requiring intermittent leave or a reduced work schedule, the
employer may require an employee to transfer to a position that better
accommodates recurring periods of leave than the employee’s regular job.
However, the alternative position must have the same rate of pay and
benefits. The new position does not have to include equivalent duties.

A pregnant employee’s health care provider may request the employee be
transferred to a less strenuous or hazardous position or given less strenuous
or hazardous duties during her pregnancy. The employer has no obligation
to create a position or move other employees to effectuate such a transfer.
CONTINUATION OF HEALTH BENEFITS WHILE ON FMLA/CFRA/PDL AND USE OF
ACCRUED TIME OFF

Health insurance benefits must be continued for the duration of FMLA/CFRA leave
up to a maximum of 12 weeks within a 12-month period (26 weeks if the employee is
taking leave to care for an injured or ill servicemember).

There is no obligation to continue benefits for employees on PDL who are not eligible
for FMLA leave (unless such benefits are provided to other employees on temporary
leaves of absence).
USE OF PAID TIME DURING FMLA/CFRA/PDL
If an employee will receive any pay during FMLA/CFRA/PDL, such as from state disability
insurance/private insurance/paid family leave benefits, the employee cannot be required
to use accrued paid time off. However, the employer should coordinate any benefits
received from SDI, etc. with the paid time the employee uses.
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11.
JOB RESTORATION FOLLOWING FMLA/CFRA/PDL
Determine the right to reinstatement to the same or an “equivalent” position:

Can the employee perform essential functions of the job?

Would the employee otherwise have been discharged for performance issues
predating the leave, or laid off due to restructuring not related to the
employee’s illness?

If the employee was notified that he or she needed to provide a return-towork certification, did the employee provide such a certification? Note: A
medical certification may be required only if the employer has a uniformly
applied practice or policy of requiring such certifications from other
employees returning to work after illness, injury or disability.
If the employee has reinstatement rights, determine whether the employee’s same or
equivalent position is available. Employers are required to reinstate employees returning
from PDL to their same position unless the employee would have been laid off, or any means of
preserving her job would have substantially undermined the employer’s ability to operate the
business safely and effectively. Employers may reinstate an employee returning from
FMLA/CFRA leave to a substantially similar position with the same pay, benefits, and hours only
if the employer can show holding the prior position open would have resulted in undue hardship
(this is one of those “crossover” issues with FMLA/CFRA and disability discrimination laws, such
as the Americans with Disabilities Act and California’s Fair Employment and Housing Act).
12.
RECORDKEEPING REQUIREMENTS
The following records must be maintained for a minimum of three years:

Basic payroll and identifying employee data.

The dates FMLA/CFRA/PDL is taken by eligible employees, including increments of
less than one full day.

Copies of employee notices of leave furnished to the employer under the
FMLA/CFRA/PDL if in writing, and copies of all general and specific written
notices/letters given to employees. Copies may be maintained in employee
personnel files.

Any documents (including written and electronic records) describing employee
benefits or the employer’s policies and practices regarding the taking of paid and
unpaid leaves.

Records of payments of employee benefits.

Records of any dispute between the employer and an eligible employee regarding
designation of leave as FMLA/CFRA/PDL, including any written statement from the
employer or the employee of the reasons for the designation and for the
disagreement.
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
Medical records created for purposes of the FMLA/CFRA/PDL must be maintained
separately from other personnel records and only accessible to those people with a
“need to know.”
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ATTACHMENT 2
REQUEST FOR LEAVE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND/OR
CALIFORNIA FAMILY RIGHTS ACT AND/OR PREGNANCY DISABILITY LEAVE LAW
DATE:
TO:
[Human Resources/Personnel]
FROM:
SUBJECT:
Request for Leave Under the Family and Medical Leave Act and/or California
Family Rights Act and/or Pregnancy Disability Leave
________________________________________________________________
I am requesting a leave for the following reason:
_____Following the birth of my child, or the placement of a child with me for adoption or foster
care (“bonding” leave).
_____A serious health condition that makes me unable to perform one or more essential
functions of my job.
_____A serious health condition affecting my _____spouse_____ registered domestic
partner_____ child_____ parent for whom I am needed to provide care.
_____A serious injury or illness affecting my _____ spouse _____ child_____ parent _____next
of kin who is a servicemember in the Armed Forces.
_____A qualifying exigency resulting from my _____spouse_____ child_____ parent’s active
duty or call to active duty in the Armed Forces to support a contingency operation.
Specify the qualifying exigency:
_____My disability due to pregnancy or pregnancy-related conditions.
During my leave, I_____ would or_____ would not like to receive my [____________] Including
_____________________________.
During my leave, I can be reached at:
,
Address
City, State and Zip Code
Telephone.
I will need a leave beginning on______________.
about ____________.
I expect my leave to continue until on or
I understand I will be required to provide a completed medical certification within 15 days of
submitting this request if the leave is for my own serious medical condition; to care for my
spouse, registered domestic partner, child, or parent with a serious health condition; or to care
for my spouse, partner, child, parent, or next of kin with a serious injury or illness in the Armed
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Forces. I also understand I will be required to provide a medical certification prior to the date
my leave is scheduled to begin if this leave request is for disability due to pregnancy, childbirth,
or a related medical condition.
Please refer to the “Family and Medical Leave” policy in the employee handbook for additional
information.
__________________
Date
______________________________
Signature of Employee
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ATTACHMENT 3
LETTER DENYING FMLA/CFRA, FMLA/PDL AND/OR PDL LEAVE
[Date]
VIA CERTIFIED MAIL
[Employee Name]
[Employee Address]
RE:
Denial of [Family and Medical Leave Act/California Family Rights
Act Leave] [Family and Medical Leave Act/Pregnancy Disability
Leave] [Pregnancy Disability Leave]
Dear _________________:
On _____we received you’re your request for leave under the [Family and Medical Leave
Act/California Family Rights Act] [Family and Medical Leave Act/Pregnancy Disability Leave
law] [Pregnancy Disability Leave Act]. Your request is denied for the following reason(s):
[You have not worked for the Company for 12 months.]
[You have not worked 1,250 hours in the 12-month period prior to the need for leave.]
[You work at a worksite that employs fewer than 50 employees within a 75-mile radius.]
[You have not provided medical certification of the need for leave.]
[You have exhausted the 12 weeks of FMLA/CFRA leave available to you.] [You have
exhausted your 26 weeks of FMLA leave to care for a servicemember available to you.]
[You have exhausted your the FMLA/PDL [or PDL] available for your current pregnancy.]
Please contact me at your earliest convenience to discuss your return to work status. I can be
reached at ______________. Thank you.
Sincerely,
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ATTACHMENT 4
FMLA/CFRA DESIGNATION LETTER—CONDITIONAL DESIGNATION
[Date]
VIA CERTIFIED MAIL
[Employee Name]
[Employee Address]
RE: Conditional Designation of FMLA/CFRA Leave
Dear ______________________:
On ______________, we received information that indicates you [are absent/will be absent]
from work for a reason that may qualify as leave under the federal Family and Medical Leave
Act (“FMLA”) and/or the California Family Rights Act (“CFRA”) due to:
[a serious health condition that makes you unable to perform one or more essential functions of
your job.]
[a serious health condition affecting your (spouse) (registered domestic partner) (child) (parent
for whom you are needed to provide care).]
[the birth of your child, or the placement of a child with you for adoption or foster care.]
[a qualifying exigency arising out of a (spouse’s)(registered domestic partner’s) (son’s)
(daughter’s) (parent’s) active duty in the Armed Forces.]
[a serious injury or illness affecting your (spouse) (registered domestic partner) (son) (daughter)
(parent)(next of kin) who is a servicemember in the Armed Forces.]
Effective the date of this letter, we are placing you on conditional FMLA/CFRA leave, pending
completion of the enclosed “California Certification of Health Care Provider” form. You must
return the completed form no later than___________. If we do not receive the completed form
by that date, your request for [further] leave will be denied and you may be subject to
disciplinary action. Once we receive the completed form, we will send you a letter describing
your rights and responsibilities under the FMLA/CFRA.
If your absence is approved as FMLA/CFRA leave, you will have ____ hours of leave available
to you as of the date of this letter. [You have used ____ hours of FMLA/CFRA leave during the
applicable 12–month period.]
Should you fail to return to work at the end of your FMLA/CFRA leave, or fail to provide
continued medical certification of your need for additional leave, the Company cannot guarantee
reinstatement to your prior position, or that any job will be available for your upon your return to
work.
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Information about state disability insurance (“SDI”) and paid family leave (“PFL”) benefits are
enclosed with this letter. It is your responsibility to apply for such benefits through the local
employment development department.
If you have any questions, please contact me at _____. Thank you.
Sincerely,
_____________________
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ATTACHMENT 5
FMLA/CFRA DESIGNATION LETTER—FINAL DESIGNATION
[Date]
VIA CERTIFIED MAIL
[Employee Name]
[Employee Address]
RE: Designation of FMLA/CFRA Leave
Dear ______________________:
On __________, we received information that indicates you [are absent/will be] absent from
work for a reason that may qualify as leave under the federal Family and Medical Leave Act
(“FMLA”) and/or the California Family Rights Act (“CFRA”) due to:
[a serious health condition that makes you unable to perform one or more essential functions of
your job.]
[a serious health condition affecting your (spouse) (registered domestic partner) (child) (parent
for whom you are needed to provide care).]
[the birth of your child, or the placement of a child with you for adoption or foster care.]
[a qualifying exigency arising out of a (spouse’s)(registered domestic partner’s) (son’s)
(daughter’s) (parent’s) active duty in the Armed Forces.]
[a serious injury or illness affecting your (spouse) (registered domestic partner) (son) (daughter)
(parent)(next of kin) who is a servicemember in the Armed Forces.]
Your time off has been approved under the FMLA/CFRA effective ______________.
Except as explained below, you have a right under the FMLA/CFRA for up to 12 workweeks of
unpaid leave in a 12-month period. You may be entitled to up to 26 weeks of leave if the leave
is to care for an ill or injured servicemember. Generally, you will be reinstated to the same or an
equivalent job with the same pay, benefits, and terms and conditions of employment on your
return from leave.
If you require intermittent leave, we will provide you with the leave your health care provider
indicates is necessary to the extent required by law. However, we reserve the right to reassign
you to a position with equivalent pay and benefits during your leave if another position is better
suited to your new temporary schedule. We will notify you if a temporary reassignment will be
made.
According to the information we received, you should be able to return to work on
___________. If you are unable to return to work by that date, you must contact
____________________ at _______________. Should you fail to return to work by this date,
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or fail to provide continued medical certification of your need for additional leave, the Company
cannot guarantee reinstatement to your prior position or that any job will be available for your
upon your return to work.
During your leave, you may use any accrued [sick/vacation/PTO] available to you. You
currently have ________ hours of accrued [sick/vacation/PTO] available. Please let me know if
you wish you use any of these hours during your leave.
[Information about state disability insurance (SDI) and paid family leave (PFL) benefits are
enclosed with this letter. It is your responsibility to apply for such benefits through the local
Employment Development Department.] Any accrued [sick/vacation/PTO] you use will be
coordinated with any SDI or PFL benefits you receive so your leave payments do not exceed
your normal rate of pay.
Under the FMLA/CFRA, you are eligible for continued health benefits during your leave for up to
a maximum of 12 weeks. If you currently contribute to the payment of the premiums for health
benefits, you must continue to do so while on leave, beginning on_______________. The
amount of each payment is $_______ and must be paid directly to the organization. This
payment is due on or before the ____ [insert day] of each month. Payment should be sent to:
____________________________. Your 12 weeks of continued coverage will end on
_____________. If you do not return to work by that date, you may be eligible to continue your
coverage through COBRA. Information regarding COBRA continuation coverage will be sent to
you at that time. You have a minimum 30-day grace period in which to make your premium
payments. If payment is not made on time, your group health insurance coverage may be
canceled. If you do not return to work following FMLA/CFRA leave for a reason other than: (1)
the continuation, reoccurrence, or onset of a serious health condition that would entitle you to
FMLA/CFRA leave; or (2) other circumstances beyond your control, you may be required to
reimburse us for our share of health insurance premiums paid on your behalf during your leave.
[You are a “key employee” as described in section 825.217 of the FMLA regulations and section
7297.2 of the California Code of Regulations. Accordingly, you may be denied reinstatement
following FMLA/CFRA leave on the grounds that reinstatement would cause substantial and
grievous economic injury to the operations of the organization. We have determined that
reinstating you to employment at the conclusion of FMLA/CFRA leave will cause substantial and
grievous economic harm to the organization. Therefore, we will determine what positions are
available to you when you are released to return to work.]
Remember, if your leave is for your own serious health condition, you will be required to present
a return-to-work certification from your health care provider prior to being restored to
employment. If we do not receive that certification, your return to work may be delayed until the
certification is provided.
While on leave, you will be required to furnish us with periodic reports every 30 days of your
status and intent to return to work. If the circumstances of your leave change and you are able
to return to work earlier than any previously indicated date, you will be required to notify us at
least two (2) working days prior to the date you intend to report to work.
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Please contact ________________________ at _______________ if you have any questions.
We wish you the best, and look forward to your return.
Sincerely,
________________
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ATTACHMENT 6
PDL/FMLA DESIGNATION LETTER
[Date]
VIA CERTIFIED MAIL
[Employee Name]
[Employee Address]
RE: Designation of PDL/FMLA Leave
Dear ______________________:
On_________________, we received information that you will need time off from work due to
your disability caused by your pregnancy or a pregnancy-related condition.
Under California law, you have a right to Pregnancy Disability Leave (“PDL”) for the period of
your actual disability up to a maximum of four months (defined as 88 work days for full-time
employees working five (5) days per week; employees working other schedules are entitled to a
pro-rata amount of leave). In addition, under the federal Family and Medical Leave Act
(“FMLA”), you have a right to up to 12 workweeks of unpaid leave in a 12-month period for the
period of disability caused by your pregnancy or related medical conditions. The PDL and
FMLA run concurrently during the period of your disability.
As of the date of this letter, we are placing you on PDL and FMLA. You have used ____ hours
of FMLA leave in the prior 12-month period. Therefore, you currently have _____ hours of
FMLA leave available to you.
If you require intermittent leave, we will provide you with the leave your health care provider
indicates is necessary to the extent required by law. However, we reserve the right to reassign
you to a position with equivalent pay and benefits during your leave if another position is better
suited to your new temporary schedule. We will notify you if a temporary reassignment will be
made.
According to the information we received, you should be able to return to work on
___________. If you have not been released by your health care provider by that date, you will
need to provide us with additional medical documentation of your need for further leave.
During your leave, you may use any accrued [sick/vacation/PTO] available to you. You
currently have ________ hours of accrued [sick/vacation/PTO] available. Please let me know if
you wish you use any of these hours during your leave.
[Information about state disability insurance (“SDI”) and paid family leave (“PFL”) benefits are
enclosed with this letter. It is your responsibility to apply for such benefits through the local
Employment Development Department.] Any accrued [sick/vacation/PTO] you use will be
coordinated with any SDI or PFL benefits you receive so your leave payments do not exceed
your normal rate of pay.
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Under the FMLA, you are eligible for continued health benefits during your leave for up to a
maximum of 12 weeks. If you currently contribute to the payment of the premiums for health
benefits, you must continue to do so while on leave, beginning on_______________. The
amount of each payment is $_______ and must be paid directly to the organization. This
payment is due on or before the ____ [insert day] of each month. Payment should be sent to:
____________________________. Your 12 weeks of continued coverage will end on
_____________. If you do not return to work by that date, you may be eligible to continue your
coverage through COBRA. Information regarding COBRA continuation coverage will be sent to
you at that time. You have a minimum 30-day grace period in which to make your premium
payments. If payment is not made on time, your group health insurance coverage may be
canceled. If you do not return to work following FMLA/CFRA leave for a reason other than: (1)
the continuation, reoccurrence, or onset of a serious health condition that would entitle you to
FMLA/CFRA leave; or (2) other circumstances beyond your control, you may be required to
reimburse us for our share of health insurance premiums paid on your behalf during your leave.
You are also eligible to take up to an additional 12 weeks of leave under the California Family
Rights Act (“CFRA”) to “bond” with your new child after your PDL/FMLA leave ends. You must
request CFRA leave at least 30 days in advance.
[You are a “key employee” as described in section 825.217 of the FMLA regulations and section
7297.2 of the California Code of Regulations. Accordingly, you may be denied reinstatement
following FMLA/CFRA leave on the grounds that reinstatement would cause substantial and
grievous economic injury to the operations of the organization. We have determined that
reinstating you to employment at the conclusion of FMLA/CFRA leave will cause substantial and
grievous economic harm to the organization. Therefore, we will determine what positions are
available to you when you are released to return to work.]
Remember, you will be required to present a return-to-work certification from your health care
provider prior to being restored to employment. If we do not receive that certification, your
return to work may be delayed until the certification is provided.
Please contact ________________________ at _______________ if you have any questions.
We wish you the best and look forward to your return.
Sincerely,
________________
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ATTACHMENT 7
PDL ONLY DESIGNATION LETTER
[Date]
VIA CERTIFIED MAIL
[Employee Name]
[Employee Address]
RE: Designation of PDL Leave
Dear ______________________:
On_________________, we received information that you will need time off from work due to
your disability caused by your pregnancy or a pregnancy-related condition.
Under California law, you have a right to Pregnancy Disability Leave (“PDL”) for the period of
your actual disability up to a maximum of four months (defined as 88 work days for full-time
employees working five (5) days per week; employees working other schedules are entitled to a
pro-rata amount of leave).
As of the date of this letter, we are placing you on PDL. You have used ____ days of PDL
leave. Therefore, you currently have _____ days of PDL leave available to you.
If you require intermittent leave, we will provide you with the leave your health care provider
indicates is necessary to the extent required by law. However, we reserve the right to reassign
you to a position with equivalent pay and benefits during your leave if another position is better
suited to your new temporary schedule. We will notify you if a temporary reassignment will be
made.
According to the information we received, you should be able to return to work on
___________. If you have not been released by your health care provider by that date, you will
need to provide us with additional medical documentation of your need for further leave.
During your leave, you may use any accrued [sick/vacation/PTO] available to you. You
currently have ________ hours of accrued [sick/vacation/PTO] available. Please let me know if
you wish you use any of these hours during your leave. If you are eligible for state disability
insurance (“SDI”), your SDI benefits and sick leave pay will be coordinated so that your SDI/sick
leave payments do not exceed your regular rate of pay.
[Information about SDI and paid family leave (“PFL”) benefits are enclosed with this letter. It is
your responsibility to apply for such benefits through the local Employment Development
Department.] Any accrued [sick/vacation/PTO] you use will be coordinated with any SDI or PFL
benefits you receive so your leave payments do not exceed your normal rate of pay.
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[You are not eligible for continued health care benefits during your leave. Your health care
benefits will end on ______________. You may, however, be eligible to continue your coverage
through COBRA. Information regarding COBRA continuation coverage is enclosed.]
Remember, you will be required to present a return-to-work certification from your health care
provider prior to being restored to employment. If we do not receive that certification, your
return to work may be delayed until the certification is provided.
Please contact ________________________ at _______________ if you have any questions.
We wish you the best and look forward to your return.
Sincerely,
________________
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ATTACHMENT 8
[NOT TO BE INCLUDED IN HANDBOOK—NOTICE TO EMPLOYEE]
FAMILY CARE AND MEDICAL LEAVE (CFRA LEAVE)
AND PREGNANCY DISABILITY LEAVE
Under the California Family Rights Act of 1993 (CFRA), if you have more than 12
months of service with us and have worked at least 1,250 hours in the 12- month period before
the date you want to begin your leave, you may have a right to an unpaid family care or medical
leave (CFRA leave). This leave may be up to 12 workweeks in a 12-month period for the birth,
adoption, or foster care placement of your child or for your own serious health condition or that
of your child, parent or spouse.
Even if you are not eligible for CFRA leave, if disabled by pregnancy, childbirth or related
medical conditions, you are entitled to take a pregnancy disability leave of up to four months,
depending on your period(s) of actual disability. If you are CFRA-eligible, you have certain rights
to take BOTH a pregnancy disability leave and a CFRA leave for reason of the birth of your
child. Both leaves contain a guarantee of reinstatement to the same or to a comparable position
at the end of the leave, subject to any defense allowed under the law.
If possible, you must provide at least 30 days advance notice for foreseeable events
(such as the expected birth of a child or a planned medical treatment for your self or of a family
member). For events which are unforeseeable, we need you to notify us, at least verbally, as
soon as you learn of the need for the leave.
Failure to comply with these notice rules is grounds for, and may result in, deferral of the
requested leave until you comply with this notice policy.
We may require certification from your health care provider before allowing you a leave
for pregnancy or your own serious health condition or certification from the health care provider
of your child, parent, or spouse who has a serious health condition before allowing you a leave
to take care of that family member. When medically necessary, leave may be taken on an
intermittent or a reduced work schedule.
If you are taking a leave for the birth, adoption or foster care placement of a child, the
basic minimum duration of the leave is two weeks and you must conclude the leave within one
year of the birth or placement for adoption or foster care.
Taking a family care or pregnancy disability leave may impact certain of your benefits
and your seniority date. If you want more information regarding your eligibility for a leave and/or
the impact of the leave on your seniority and benefits, please contact ________.
[Note: Employers must provide pregnant employees with notice of their rights under
PDL as soon as the employer learns of an employee’s pregnancy. This notice, “Notice
B,” is included in California Code of Regulations section 7291.16, and is for use by
employers subject to CFRA or FMLA.]
© Shaw Valenza LLP 2008
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ATTACHMENT 9
CALIFORNIA CERTIFICATION OF HEALTH CARE PROVIDER
FAMILY AND MEDICAL LEAVE/CALIFORNIA FAMILY RIGHTS ACT/
PREGNANCY DISABILITY LEAVE
1.
Employee’s Name:
2.
Employer’s Name:
3.
Employee’s Supervisor’s Name and Telephone Number:
4.
Patient’s Name (if different from employee):
5.
The attached “Definitions” describe what is meant by a “serious health condition” under
the Family and Medical Leave Act (“FMLA”) and the California Family Rights Act
(“CFRA”). Does the patient’s condition2 qualify under any of the categories described?
If so, please check the applicable category.
(1)_____(2)_____(3)_____(4)_____(5)_____(6)_____None_____
6.
2
(a)
State the approximate date the condition commenced and the probable duration
of the condition (and also the probable duration of the patient’s present
incapacity3, if different):
(b)
Will it be necessary for the employee to work only intermittently or to work on a
less than full schedule as a result of the condition (including for treatment
described in question 7 below)?
The information sought on this form relates only to the condition for which the employee is taking leave.
“Incapacity” for purposes of this form means the inability to work, attend school or perform other regular
daily activities due to the serious health condition, treatment for such condition or recovery from such
condition.
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If the answer to question 6(b) is “yes,” please give the probable duration of the
necessary intermittent leave or reduced schedule and the work schedule appropriate for
the employee during this time:
7.
(c)
If the condition is a chronic condition (condition #4) or pregnancy, state whether
the patient presently is incapacitated and the likely duration and frequency of
episodes of incapacity:
(a)
If additional treatments will be required for the condition, provide an estimate of
the probable number of such treatments:
(b)
If the employee will be absent from work or other daily activities because of
treatment on an intermittent or part-time basis, please provide an estimate of the
probable number and interval between such treatments, actual or estimated
dates of treatment if known, and period required for recovery, if any:
(c)
If any of these treatments will be provided by another provider of health services
(e.g., physical therapist), please state the nature of the treatments:
(d)
If a regimen of continuing treatment by the patient is required under your
supervision, provide a general description of such regimen (e.g., prescription
drugs, physical therapy requiring special equipment):
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8.
(a)
If medical leave is required for the employee’s absence from work because of the
employee’s own condition (including absences due to pregnancy or chronic
condition), is the employee unable to perform work of any kind?
(b)
If able to perform some work, is the employee unable to perform any one or more
of the essential functions of the employee’s job with or without reasonable
accommodations (the employee or the employer should supply you with
information about the essential job functions)?
If the answer to question 8(b) is “yes,” please list the essential functions the employee is
unable to perform with or without reasonable accommodation and what reasonable
accommodations, if any, are suggested:
9.
(c)
If neither (a) nor (b) above applies, is it necessary for the employee to be absent
from work for treatment?
(a)
If leave is required to care for a spouse, registered domestic partner, child, or
parent (or next of kin for servicemember FMLA only) of the employee with a
serious health condition, does the family member require assistance for basic
medical or personal needs or safety, or for transportation?
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(b)
If the answer to question 9(a) is “no,” would the employee’s presence provide
psychological comfort beneficial to the family member or assist in the family
member’s recovery?
(c)
If the family member will need care only intermittently or on a part-time basis,
please indicate the probable duration and frequency of this need:
Signature of Health Care Provider
Type of Practice
Address
City, State and Zip Code
Telephone Number
Date
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The following is to be completed by an employee needing time off to care for a spouse,
registered domestic partner, child, or parent (or “next of kin” for servicemember FMLA
only):
State the care you will provide and an estimate of the period during which care will be provided,
including a schedule if leave is to be taken intermittently or if it will be necessary to work less
than a full schedule:
________________________________
Employee’s Signature
________________________________
Date
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DEFINITIONS
A “serious health condition” means an illness, injury, impairment, or physical or mental condition
that involves one of the following:
1.
Hospital Care
Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility,
including any period of incapacity or subsequent treatment in connection with or consequent to
such inpatient care.
2.
Absence Plus Treatment
A period of incapacity of more than three (3) consecutive calendar days (including any
subsequent treatment or period of incapacity relating to the same condition), that also involves:
(a)
treatment4 two (2) or more times by a health care provider, by a nurse or
physician’s assistant under direct supervision of a health care provider, or by a provider of
health care services (e.g., physical therapist) under orders of, or on referral by, a health care
provider; or
(b)
treatment by a health care provider on at least one (1) occasion which results in
a regimen of continuing treatment5 under the supervision of a health care provider.
3.
Pregnancy
Any period of disability due to pregnancy, or pregnancy-related conditions, or for prenatal care.
4.
Chronic Conditions Requiring Treatments
A chronic condition which:
(a)
requires periodic visits for treatment by a health care provider, or by a nurse or
physician’s assistant under direct supervision of a health care provider;
(b)
continues over an extended period of time (including recurring episodes of a
single underlying condition); and
(c)
may cause episodic, rather than a continuing period of incapacity (e.g., asthma,
diabetes, epilepsy, etc.).
“Treatment” includes examinations to determine if a serious health condition exists and evaluations of
the condition. “Treatment” does not include routine physical examinations, eye examinations or dental
examinations.
4
A “regimen of continuing treatment” includes, for example, a course of prescription medication (e.g., an
antibiotic) or therapy requiring special equipment to resolve or alleviate the condition. It does not include
the taking of over-the-counter medication, such as aspirin, antihistamines, or salve; or bed rest, drinking
fluids, exercise and other similar activities that can be initiated without a visit to a health care provider.
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5.
Permanent/Long-term Conditions Requiring Supervision
A period of incapacity which is permanent or long-term due to a condition for which treatment
may not be effective. The employee or family member must be under the continuing
supervision of, but need not be receiving active treatment by, a health care provider. Examples
include Alzheimer’s, a severe stroke, or the terminal stages of a disease.
6.
Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery for such
treatments) by a health care provider or by a provider of health care services under orders of, or
on referral by, a health care provider, either for restorative surgery after an accident or other
injury, or for a condition that would likely result in a period of incapacity of more than three
consecutive calendar days in the absence of medical intervention or treatment, such as cancer
(e.g., chemotherapy, radiation, etc.), severe arthritis (e.g., physical therapy) kidney disease
(e.g., dialysis).
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ATTACHMENT 10
LETTER GRANTING ADDITIONAL LEAVE
AFTER EXPIRATION OF FMLA/CFRA OR FMLA/PDL LEAVE
[DATE]
VIA CERTIFIED MAIL
[EMPLOYEE NAME]
[EMPLOYEE ADDRESS]
RE:
Return-to-Work Status
Dear _____________:
As you know, you have been on [an FMLA/CFRA leave of absence][an absence due to your
pregnancy or childbirth] from [insert date] through [insert date], based on information
provided by your health care provider. Your leave expired on [insert date]. However, we
understand you are still unable to return to work at this time.
Pursuant to our policy, we are willing to extend your unpaid leave of absence through [insert
date.] However, because of our business needs, we are unable to extend your leave past
[insert same date as above]. If you are unable to return to work on [insert same date as
above], and perform the essential functions of your job with or without reasonable
accommodation, we will proceed with hiring a replacement for your position. Should it become
necessary to replace you we will discuss other options available to you at that time.
Please call me at ____ - ____ - _____ no later than [insert date] to discuss your return to work
status. Thank you for your cooperation.
Sincerely,
_____________________
© Shaw Valenza LLP 2008
46025.6.99999.002
ATTACHMENT 11
LETTER REGARDING ADDITIONAL LEAVE
AFTER EXPIRATION OF FMLA/CFRA LEAVE
[Date]
VIA CERTIFIED MAIL
[Employee Name]
[Employee Address]
RE:
Return-to-Work Status
Dear ___________:
We hope this letter finds you feeling better. As you know, you have been on a leave of absence
since __________________. As of _________, you will have exhausted all leave available to
you under the Family and Medical Leave Act, California Family Rights Act, and our policy.
On ___________, we received a note from your health care provider estimating a return to work
date of ____________.
As you know, you hold an important position with the organization. Your continued absence
naturally is a burden on your co-workers and disruptive to operations. For that reason, we
cannot repeatedly extend your leave of absence, or extend it indefinitely. To evaluate your
request for additional time off, or whether there are alternatives to additional leave, we need to
receive medical documentation from your treating health care provider. Please send the
attached questionnaire to your treating health care provider and ensure it is completed and
returned to me no later than the close of business on ___________________.
If your health care provider does not timely respond to the questionnaire, we will have no basis
to provide you with additional leave or other accommodation. In that event, we may end your
employment with us. If your health care provider timely responds but clarification is required,
we may request clarification from your health care provider. Alternatively, we may request your
health care provider to forward to another provider of our choosing a photocopy of your relevant
medical records and/or require you to undergo a relevant medical examination at the
organization’s expense.
Finally, should your health care provider indicate there is some accommodation other than
additional leave that will allow you to return to work before _________we will consider providing
the accommodation or propose alternatives. Failure to cooperate in this medical review process
may result in the termination of your employment.
We look forward to hearing from you.
___-____. Thank you.
If you have any questions, please contact me at ___-
Sincerely,
© Shaw Valenza LLP 2008
46025.6.99999.002
LETTER TO HEALTH CARE PROVIDER REGARDING
REASONABLE ACCOMMODATION QUESTIONNAIRE
[Date]
[Name/Address of Health Care Provider]
RE:
Reasonable Accommodation
Dear Dr. ________________:
To provide me with additional time off from work, my employer has requested that you answer
the questions on the attached questionnaire by ___________________ and return the form to
me. I will return the completed questionnaire to my employer.
By my signature below, I authorize you to discuss any of your responses with my employer or a
health care provider of my employer’s choosing. This letter also authorizes you to submit to a
health care provider of my employer’s choosing a copy of my medical records pertaining to the
medical condition for which I am seeking additional time off. If you need me to sign a separate
medical records consent form, please let me know and I will do so.
Thank you for your prompt attention to this matter. Again it is important that I receive the
completed questionnaire no later than _____________because my employer has indicated that
additional time off will not be approved unless it has received adequate and timely medical
justification.
Sincerely,
Employee’s Name
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REASONABLE ACCOMMODATION QUESTIONNAIRE
Employee Name: _________________________________(“Employee”)
Date: _____________
1.
When was your most recent evaluation of Employee?
2.
Does Employee have a physical or mental impairment?
Yes 
No 
If yes, is the impairment long-term or permanent?
Yes 
No 
Yes 
No 
If no, how long will the impairment likely last?
3.
Does the impairment affect a major life activity?
If yes, what major life activity(s) is/are affected (check all applicable boxes below)?
4.
 Caring for
Self
 Breathing
 Thinking
 Learning
 Reproduction
 Interacting
with Others
 Working
 Toileting
 Sitting
 Other:
(describe)
 Performing
Manual
Tasks
 Walking
 Hearing
 Lifting
 Standing
 Seeing
 Sleeping
 Reaching
 Speaking
 Concentrating
Is Employee limited in one or more of the major life
activities check above?
If yes, please describe the limitations.
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Yes 
No 
5.
Employee currently works in the position of [insert position]. Please review the
attached job description for this position and identify any job function you believe
Employee is unable to perform as a result of the condition(s) for which you are providing
treatment.
6.
How does the employee’s limitation(s) interfere with his/her ability to perform the job
function(s)?
7.
What accommodations, if any, may be made to Employee’s job functions to enable
Employee to perform the job functions listed in response to question #5 above without
endangering Employee’s health or safety or the health or safety of others in the
workplace?
8.
Are you aware of any medication Employee is taking that would limit Employee from
performing the essential job functions described in the attached job description? If so,
please describe the limitations and whether any accommodation would ameliorate the
limitations.
9.
You stated in your note dated [insert date], that Employee may return to work on [insert
date]. Is that return date reasonably definite?
What is the likelihood you will require Employee to be off work for additional time?
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10.
Are there any alternatives to time off from work that would enable Employee to perform
his/her job functions now or sooner than the additional time off you have prescribed? If
so, please recommend those alternatives.
11.
Is there anything else we should know that would be helpful for us to determine
appropriate accommodations for Employee?
Please sign and date this form below and return it directly to Employee.
THANK YOU FOR YOUR COOPERATION AND ASSISTANCE.
______________________________
Signature of Health Care Provider
______________________________
Date
______________________________
Health Care Provider’s Name
______________________________
Address
______________________________
City
State Zip
______________________________
Telephone
Fax
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ATTACHMENT 12
RETURN-TO-WORK CERTIFICATION
Employee's Name: _____________________
Date on Which Employee May Return to Work:_______________
I hereby certify that the employee named above may return to work on the above date.
_____ The employee is able to perform the essential functions of the position. My opinion is
based on a review of the position description provided to me and/or a discussion with the
employee of the position's essential functions.
_____ The employee cannot perform the following essential functions of the position:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
My opinion is based on a review of the position description provided to me and/or a discussion
with the employee of the position's essential functions.
______________________________
Signature of Health Care Provider
______________________________
Date
______________________________
Health Care Provider’s Name
______________________________
Address
______________________________
City
State Zip
______________________________
Telephone
Fax
© Shaw Valenza LLP 2008
46025.6.99999.002