CALIFORNIA LUTHERAN UNIVERSITY
EMPLOYEE REQUEST FOR LEAVE OF ABSENCE
ADMINISTRATION, FACULTY AND STAFF
Complete this form for all leave of absence requests including vacation and sick leave requests.
Employee Name
Date
Department
Job Title
Supervisor Name
Extension
Initial Request
Request for Leave Extension
Leave Start Date
Leave End Date
TYPE OF LEAVE
MEDICAL LEAVE REQUEST (Requires Additional Documentation) (see page 2)
Pregnancy Disability Leave
Maternity Leave
Paternity/Adoption/(Foster Care)
Family & Medical Leave Act (FMLA)
Self
Birth of Child
Family Need
For any medical absence of more than five (5) days or a surgical procedure, a completed Return to Work Certification
must be provided to Human Resources prior to resuming current position.
Leaves which qualify under Family Medical Leave Act (FMLA) will be counted against employee’s FMLA entitlement.
Each leave will be evaluated as defined under CLU Policy, FMLA, California Family Rights Act (CFRA)
Employee will be placed on a PROVISIONAL FMLA for 10 days pending receipt of Medical Certification.
LEAVE REQUEST (Requires Additional Documentation) (see page 2)
Type of Leave Requested
Paid
Unpaid
Vacation
Sick Leave
Bereavement
Jury Duty
Military Spouse/Domestic Partner Leave
Child School Leave
Other / Personal Leave (describe)
I understand the CLU leave policy and will provide necessary documentation.
Employee Signature
Date
Supervisor Approval
Date
Dean or Vice President Approval
(for faculty and director level employees)
Date
Human Resources Eligibility
Verification
Date
INSTRUCTIONS FOR COMPLETING THE LEAVE REQUEST FORM
The request for leave of absence must be reviewed and signed off by the Supervisor and Vice President, pending final
verification of eligibility by Director of Human Resources. Requests should be submitted at least two weeks prior to
effective date. If circumstances prevent appropriate notice, the employee should inform their supervisor as soon as
possible within learning of the need for a leave.
EMPLOYEE’S RESPONSIBILITY
If employee is on a medical leave, a medical release must be submitted to Human Resources prior to returning to
work.
Eligibility for leave programs will be determined by Human Resources based on the employee’s length of service
and eligibility for leaves as defined by CLU policy, state and federal law (FMLA, CFRA, etc.).
For any medical or FMLA-related absence of more than three (3) consecutive days, a Return to Work Certification
form must be completed and returned to Human Resources prior to being restored to your position.
Unless on reduced work as prescribed by a doctor, while on medical leave, work should not be conducted.
FMLA LEAVE INFORMATION
As required by the FMLA, you must keep human resources and your supervisor informed of changes to your
leave.
When applying for Family Medical Leave, a signed Employee Request for Leave of Absence form must be
received in Human Resources with your completed Employee Request for Leave of Absence form. The
Certification of Health Care Provider form must be provided to Human Resources within 15 days from the date
the provisional FML (effective FMLA date of leave) was approved. Please schedule an appointment with Human
Resources (805) 493-3177.
All medical certifications must be submitted to Human Resources prior to final approval of FML leave.
While on approved leave, CLU will continue to pay their portion of your current medical, dental and vision
premium, and you will be expected to pay any portion of premium currently ascribed to you (e.g. your
dependent coverage, etc.). If you chose to continue your leave past the time approved by CLU and FMLA/CFRA,
you will be given the opportunity to continue your insurance coverage through COBRA election. Please review
your handbook for detailed description of CLU Leave of Absence Policy.
You may be eligible for Family Medical Leave (FML) if you have been employed by California Lutheran University
for at least twelve months or one academic year (Faculty), not necessarily continuously. The Family Medical
Leave Act provides 12 weeks of unpaid leave during a 12 month period for a qualifying event.
FML runs concurrently with CFRA. Qualifying events are classified as the following:
o You are unable to perform the essential functions of your own job because of your own serious health
condition; or
o To care for your child after birth, or placement for adoption or foster care; or
o To care for your spouse, son or daughter, or parent, who has a “serious health condition”.
For additional information please read the FML information provided on the Human Resources Website. Leaves for FML
purposes, paid or unpaid, will be counted toward the 12-week FML entitlement. A Certification of Health Care Provider
must be provided to Human Resources in order to determine eligibility.
CALIFORNIA LUTHERAN UNIVERSITY
LEAVE OF ABSENCE NOTIFICATION FORM
ADMINISTRATION, FACULTY AND STAFF
EMPLOYEE NAME
DATE
On ________________________Human Resources received your paperwork requesting a leave of absence.
This is to inform you that you are ______ eligible ________ not eligible for leave of absence as noted below:
Pregnancy Disability Leave
Maternity Leave
Paternity/Adoption/(Foster Care)
Family & Medical Leave Act (FMLA)
Vacation
Sick Leave
Bereavement
Jury Duty
Military Spouse/Domestic Partner Leave
Child School leave
Other
Your leave of absence will begin _____________________ .
Your expected return to work date is ______________________.
You will be eligible to use your accrued _____________ hours of paid vacation and/or your accrued
____________ hours of paid sick leave during this time. Contact payroll to ensure timely coordination of
accrued time.
This leave _______will ________ will not be counted against your annual FMLA leave entitlement.
CFR _______ will _______ will not run concurrently with FMLA leave.
Your leave will be taken ________ continuously ________ intermittently. If intermittently, please submit a work
schedule agreeable to you and your supervisor.
You will submit paperwork to Human Resources from a qualified medical practitioner verifying serious health
need for you or family member.
FOR HUMAN
RESOURCES
DATE