(1) Letter Requesting Leave to be Taken in One Block of Time:
To: (1) ________________
From: (2) ________________
Re: Notice of the Need for FMLA/CFRA Leave
Date: (3) ________________
This memo is to notify you of my need for leave under the Family and Medical Leave Act and the California Family Rights Act. I require a leave of absence from (4) to _. I have a serious health condition that involves continuing treatment by a health care provider. Because of this serious health condition, I am temporarily unable to work during this period of time. (5) [I have attached a completed certification from my doctor documenting my need for leave.]
It is my understanding that I am eligible for up to 12 weeks of leave per year under the Family and Medical Leave Act and the California Family Rights Act, and that I will be reinstated to my job after my leave. (6) [It is also my understanding that (7)__ will continue my health insurance during my leave.]
The Family and Medical Leave Act specifies that employers must provide specific, written notice to an employee of rights and responsibilities regarding leave within a few business days of when that employee gives notice of the need for leave. 29 C.F.R. º 825.301. I look forward to receiving this information from you.
Please let me know immediately and in writing if you require anything further from me. I appreciate your assistance with this matter.
(1) Name of Director of Human Resources, Supervisor, or Another Manager
(2) Your Name, Job Title
(3) Today’s Date
(4) Fill in these blanks with the start and end date of your leave of absence.
(5) Although medical certification is not required unless your employer asks for it, to protect your rights fully, include this sentence and attach the certification. You do not need to disclose your diagnosis to certify your need to take leave – see the CFRA certification form, p. __.
(6) Insert the sentence in brackets if your receive health insurance from your employer.
(7) Name of employer.
(2) Letter Requesting Intermittent Leave or Reduced Schedule:
To: (1) ____________________
From: (2) __________________
Re: Notice of the Need for FMLA/CFRA Leave
Date: (3) ________________
This memo is to notify you of my need for leave under the Family and Medical Leave Act and the California Family Rights Act. I have a serious health condition that involves continuing treatment by a health care provider.
(4) Because of this serious health condition, it is medically necessary to change my work schedule to ______. (5)[Because this serious health condition is chronic and causes episodic periods of incapacity, it was medically necessary for me to take leave on _.] (6) [Because this serious health condition is chronic and causes episodic periods of incapacity, it is medically necessary for me to take leave when I am temporarily incapacitated due to this condition.]
(7) [I have attached a completed certification from my doctor documenting my need for leave.]
It is my understanding that I am eligible for up to 12 weeks of leave per year under the Family and Medical Leave Act and the California Family Rights Act, and that I will be reinstated to my job after my leave. (8) [It is also my understanding that (9)__ will continue my health insurance during my leave.]
The Family and Medical Leave Act specifies that employers must provide specific, written notice to an employee of rights and responsibilities regarding leave within a few business days after that employee gives notice of the need for leave. 29 C.F.R. º 825.301. I look forward to receiving this information from you.
Please let me know immediately and in writing if you require anything further from me. I appreciate your assistance with this matter.
(1) Name of Director of Human Resources, Supervisor, or Another Manager
(2) Your Name, Job Title
(3) Today’s Date
(4) Include this sentence if you need a reduced schedule. Fill in the blank with the schedule your doctor says is medically necessary (e.g., working Monday, Wednesday and Friday).
(5) Include this sentence if you missed work for a day or two because of your HIV infection or related illnesses. Fill in the blank with the day(s) you missed. Provide this notice as soon as possible, but no later than one or two days after you learned of your need for leave.
(6) Include this sentence if your doctor certifies that in the future, HIV or related illnesses will make you too sick to work for a day or so.
(7) Although medical certification is not required unless your employer asks for it, to protect your rights fully, include this sentence and attach the certification. You do not need to disclose your diagnosis to certify your need to take leave – see the CFRA certification form, p. __.
(8) Insert the sentence in brackets if your receive health insurance from your employer.
(9) Name of employer.