TO: (1) _____________________
FROM: (2) _____________________
RE: Request for Leave of Absence
DATE: (3) _____________________
This letter is to notify you of my need for leave under the Pregnancy Disability Leave Act (PDL). If you are not the appropriate person to receive this notice, please notify me immediately, and forward this letter to the person who handles pregnancy-related leaves of absences.
I need a leave of absence because I am, or will be, disabled by a pregnancy, childbirth, or a related medical condition. I anticipate I will need a leave of absence for my pregnancy-related disability from (4) ____________to ____________. Under the Pregnancy Disability Leave Act, I am entitled to job-protected leave while I am disabled by pregnancy or childbirth and to thereafter return to my same job. Cal . Gov . Code § 12945.
(5) [***If you plan to take additional bonding leave after you recover from childbirth, indicate that here (see note below for information on eligibility): After I recover from childbirth, I plan to take [___] additional weeks to bond with my child. Under the California Family Rights Act, I am entitled to 12 more weeks of job-protected bonding leave, after I recover from childbirth. Cal. Gov. Code § 12945.2.
Please let me know immediately and in writing if you require a certification from my health care provider documenting my need for pregnancy disability leave.
Thank you.
(1) Name of Human Resources director, supervisor, program director, or another manager
(2) Your name
(3) Today’s date
(4) Fill in these blanks with the start and end date of your leave of absence. If you have notice of the day in advance, you should notify your employer at least 30 days before your leave. If you require leave suddenly, you should notify your employer as quickly as possible.
(5) After you recover from childbirth-related disability, you may be eligible for 12 more weeks of job-protected bonding leave if: 1) you have worked 1250 hours within the last year; 2) your employer has 5+ employees; and 3) you have worked for your employer for at least one year. If you are eligible and want to take bonding time, fill in how many weeks you plan to take.
Last updated: January 2025