Yosemite Community College District
Human Resources Operations
Benefits Office
FMLA CHECKLIST
Eligible District employees may take unpaid leave of up to 12 weeks for qualified health and family reasons.
Purpose of FMLA is to provide employees reasonable leave to care for an eligible family member, or the
employee himself or herself, in the event of a serious health condition, or to enable the employee to care for a
child within one year of the child’s adoption or receipt into foster care.
Employee shall notify immediate supervisor intent of applying for FMLA. Submit completed forms and
documentation to Human Resources Operations/Benefits Office prior to requested medical leave.
_ FMLA GUIDELINES. Read and review
_ SERIOUS HEALTH CONDITION. Read and review
_ FMLA APPLICATION. Original signed by employee and immediate supervisor
_ HEALTH CARE PROVIDER CERTIFICATION STATEMENT. Original completed
by treating physician
_ DOCTOR’S NOTE ON LETTERHEAD FOR PERIOD OF ABSENCE. Dates of
absence with expected return to work date.
_ YCCD ABSENCE FORMS FOR PERIOD OF ABSENCE. Original signed by
employee and immediate supervisor (to be submitted with application packet)
I have read and reviewed the FMLA guidelines. I acknowledge I must provide my supervisor and Human
Resources Operations/Benefits Office with updated doctor’s notes for the duration of my Family Medical Leave
absence.
____________________________________ _____________________
Employee Signature Date
