Medical Leave Request - Advance Notice Provided
(Date)(Employee Name)
(Employee Address)
Dear (Employee Name):
Your upcoming leave of absence [or reduced work schedule, whichever is applicable] may qualify as a Family and Medical Leave under [PPSM, APM or applicable Union contract]. A Family and Medical Leave is also considered time taken under the federal Family Medical Leave Act (FMLA) and the state California Family Rights Act (CFRA), which allow a qualified employee up to 12 weeks of unpaid leave in a calendar year. I have enclosed copies of Your Rights and Obligations Under the Federal Family and Medical Leave Act of 1993 (FMLA) and Your Rights and Obligations Under the California Family Rights Act (CFRA) for your review. You should also refer to the applicable portions of [PPSM, APM, or appropriate collective bargaining agreement].
Several other important forms are also enclosed: the Leave of Absence Request Form; the Medical Certification Form; the Family and Medical Leave Benefits Checklist; your job description and Physical, Environmental and Mental Demands (PEM) form, and the Return to Work Certification form.
At this time we are provisionally designating your anticipated time off [reduced work schedule] as FMLA/CFRA leave effective [date].
Please complete the employee sections of both the Leave of Absence Request Form and the Medical Certification Form. You should give your health care provider a copy of your job description and PEM and have her/him complete the remainder of the Medical Certification Form. Approval of your leave of absence is contingent upon receipt of medical certification, which must be completed and returned to me within fifteen (15) calendar days of the date of this letter. Failure to provide required medical certification may result in delay or denial of leave.
You may elect to substitute paid accrued vacation and/or sick leave for unpaid Family and Medical Leave to the extent permitted under policies or collective bargaining agreements. As of this date, you have (xx) hours of sick leave and (xx) hours of accrued vacation. Please complete the enclosed Leave of Absence Request form, and return it as soon as possible, advising us of how many accrued sick leave and vacation hours you wish to use.
If you have any questions, please call me at (telephone number).
Sincerely,
(Supervisor’s Name)
cc: DPM
DBC
Enclosures: [Manager/Supervisor: Be sure to list as enclosures any documents mentioned in this letter--including contract and policy sections--plus any additional information you believe will be useful to the recipient.]