Cerritos College
Human Resources Department
(562) 860-2451, Extension 2284
Verification of Bereavement Leave Form
Classified Employees
According to the provisions of Article 14.1 of the collective bargaining agreement between Cerritos
College District and the California School Employees Association (CSEA), Chapter #161, the District
agrees to grant necessary leave of absence with pay at the unit employee’s regular rate not to exceed
three (3) days, or five (5) days if 200 or more miles of one-way travel from the campus is required, on
account of the death of any member of the immediate family of a unit employee. Members of the
immediate family shall mean the father, mother, brother, sister, spouse, registered domestic partner (as
defined in California Family Code Section 297), child, grandchild, stepfather, stepmother, stepson,
stepdaughter, mother-in-law, father-in-law, brother-in-law, sister-in-law, son-in-law, daughter-in-law,
grandmother, grandfather, grandfather-in-law, grandmother-in-law, nephew, niece, aunt (3-days
maximum), uncle (3-days maximum), foster parents in lieu of father or mother, foster children, former
legal guardian or legal ward living in the employee’s immediate household, and any relative living in
the employee’s immediate household.
Furthermore, the CSEA collective bargaining agreement, section 14.4 states that unit employees shall
be required to complete a leave verification form provided by the District and provide such proof of
eligibility for Bereavement Leave benefits as may be required by the District.
Employees requesting approval for Bereavement Leave must complete the following information and
submit to the supervisor prior to starting the leave (except in emergency situations).
Employee Name:
Position Held
Request Bereavement
Leave Dates:
From To
Family Member Name(s):
Place/location (Please indicate city and state)
I hereby attest that the information herein submitted is truthful and accurate.
Employee’s Signature
Immediate manager receipt of request for Bereavement Leave:
Supervisor’s Signature
In order to be compensated according to the provisions of Article 14 of the CSEA collective bargaining
agreement, employees are required to submit proof of eligibility for Bereavement Leave (e.g.,
obituary, death certificate, funeral notice, etc.) the first workday back from such leave.