Medical Leave in Progress - No Medical Certification Received
(Date)
(Employee Name)
(Employee Address)
Dear (Employee Name):
We are sorry that you are ill and are concerned about you. (or any personalized opening that you prefer.) We wanted you to know that your leave may qualify as a Family and Medical Leave under [University policy 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), and allows 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 (CRFA) for your review. You should also refer to the applicable portions of [PPSM, APM or applicable collective bargaining agreement].
Several 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.
Effective [date], your time away from work is being provisionally designated as leave under the FMLA and CFRA.
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 applicable policy or collective bargaining agreement. In accordance with [PPSM, APM or applicable collective bargaining agreement], your sick leave hours are being applied toward this period of absence. 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 much accrued sick leave and vacation you wish to use. Unless we hear from you, your unpaid leave of absence will begin once your sick leave is exhausted.
Before returning to work, please have your health care provider review
the enclosed job description and complete the Return to Work Certification
form. Please bring the completed form with you on the day you return
to work. 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.]