THE CALIFORNIA STATE UNIVERSITY
FAMILY AND MEDICAL LEAVE (FMLA/CFRA) NOTICE AND REQUEST FORM
Notice to Employee: If the leave you are requesting meets the federal and/or state Family and Medical Leave (FMLA/CFRA)
requirements, you should be aware of the following rights and obligations:
The period of this leave will be counted as federal/state Family and Medical Leave in determining your future eligibility for
additional FMLA/CFRA leaves.
If your leave is due to a serious health condition (either your own, your spouse’s or your child’s), you must provide medical
certification within 15 days. Approval of your leave may be withheld until you comply with certification requirements. Prior to
returning to work, you will be required to present a “fitness for duty” certificate if the leave is due to your own health condition.
If your leave is due to caring for a family member who sustains a serious injury or illness or a “qualifying exigency” that arises
from the family member’s line of duty in the US Armed Services medical certifications will be required. Family is defined as
spouse, domestic partner, son, daughter, or parent of employee in the US Armed Forces.
Additional information
available in Human Resources.
Unless you are covered by a bargaining agreement which states otherwise, your personal holiday and any accumulated
vacation and CTO leave credits will be used prior to placing you on unpaid leave of absence. If appropriate, accumulated sick
leave may be used as a mutually agreed upon by you and the appropriate administrator.
For the period of unpaid FMLA/CFRA, the CSU will continue to pay its portion of your medical, dental and vision premiums
paid on your behalf during the unpaid portion of your leave. An accounts receivable will be established for any employee
premiums required during unpaid leave. If you wish to discontinue medical coverage during the unpaid leave, you may
reinstate it upon return.
If you do not return from FMLA/CFRA leave, the CSU will require you to reimburse it for medical, dental and vision premiums
paid on your behalf during the unpaid portion of your leave. However, no reimbursement will be required if you do not return
because of a serious health or if you are unable to return due to circumstances which are outside of your control.
Upon you return to work, you have the right to reinstate to the same position or to another position with equivalent benefits,
pay and conditions of employment. However, you will have no different rights than if you were actively at work rather than on
leave; this exception could affect your reinstatement in the case of layoff, for example.
Employee Leave Request: I request FMLA/CFRA leave for the following reason (check one):
Birth, adoption, foster care placement ---- Date of Action/Due Date: _________________________
Care for family member ----Relationship: ___________________________________
Own illness
Care for Family Member in military
Last day worked or Start of FMLA: ________________ Expected return to work or End of FMLA Date: __________________
FMLA Request for: Full-Time Partial Leave Intermittent
If FMLA is unpaid: Please continue these insurances (circle yes or no for each plan):
Medical (Yes / No ) Dental (Yes / No ) Vision (Yes / No )
Employee Name (Please Print): ______________________________ CSUF ID #: ________________
Home Address:_______________________________________________________ Home./Cell Ph: _______________________
City: ____________________________________________ State: ____________ Zip Code: _______________________
Department: ________________________________ _ Office Ph: ______________________
*Signature: ___________________________________________________________ Date: _____________________________
Human Resources 04/2013
For Human Resources Use Only: Copy to Employee:____________
Notification Date: __________________ Staf
: ______ Faculty: _______ MPP: ______
FMLA/CFRA Effective Date:
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