Medical Leave in Progress - No Certification of “Serious Illness” Received
(Date)
(Employee Name)
(Employee Address)
Dear (Employee Name):
We are so sorry that you are ill and are concerned about you (or any personalized opening that you prefer.) We have received your health care provider’s note. However, we still need written confirmation that your condition qualifies you for a Family and Medical leave.
Pending receipt of medical certification, we are provisionally designating your time off as a Family and Medical Leave in accordance with [PPSM, APM, or applicable union contract] effective [date]. 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) and the Family and Medical Leave Benefits Checklist; for your review. You should also refer to the applicable portions of [PPSM, APM, or applicable collective bargaining agreement].
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 returned to us with fifteen (15) calendar days of the date of this letter. Failure to provide required medical certification may result in delay or denial of leave.
In accordance with [PPSM, APM or applicable collective bargaining agreement], your sick leave hours will be applied toward this period of absence. As of this date, you have (xx) hours of sick leave and (xx) of accrued vacation. If your sick leave runs out, you may request to use your accrued vacation. Please complete the Leave of Absence Request Form or provide us with a note, as soon as possible, letting us know if you wish to apply accrued vacation to any portion of your absence. Unless we hear from you, your unpaid Leave of Absence will begin once your sick leave is exhausted.
Please remember, that on returning to work, you will need to submit a completed Return to Work Certification form (enclosed).
Please call me at (telephone number) if you have any questions.
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.]