Fillable Medical Leave Application Medical Leave Application

Fill Online, Printable, Fillable, Blank Medical Leave Application Medical Leave Application Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY, FRESNO pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Medical Leave Application Medical Leave Application

On average this form takes 12 minutes to complete

The Medical Leave Application Medical Leave Application form is 1 page long and contains:

  • 0 signatures
  • 51 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Fresno

BROWSE CALIFORNIA STATE UNIVERSITY, FRESNO FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
__ __ __ __ __ __ __ __ _

(UNITS: CSUEU- 2, 5, 7 & 9, UAPD-1, CFA- 3, SETC-6, SUPA-8, C99 & E99)
*Faculty Leave Sharing Agreement :
Dean of Dept.
Spouse/Partner
Work schedule
Human Resources Manager Benefits Date
Direct Pay
Are you on an "Alternative" Work Schedule?
CALIFORNIA STATE UNIVERSITY, FRESNO - HUMAN RESOURCES
SECTION 1. EMPLOYEE INFORMATION
HOME/CELL PHONE
DEPARTMENT
MAILING ADDRESS
MANAGER/ADMINISTRATOR
Staff
Faculty
MPP/Confidential
Unit11
CURRENT TIMEBASE/PAY PLAN
FT
PT
AY
12 MTH
10/12
11/12
YES
NO
EMPLOYMENT STATUS
TENURED
PERMANENT
TEMPORARY
PROBATIONARY
Have you had any prior employment with a CSU/State of California?
YES
NO
HUMAN RESOURCES CONTACT
PHONE NUMBER
LAST DAY PHYSICALLY WORKED
FML EFFECTIVE DATE
ESTIMATED START DATE
ESTIMATED END DATE
APPROVED START DATE
APPROVED END DATE
PAID
FULL LEAVE
PARTIAL LEAVE FROM
WILL BE WORKING AN "ALTERNATE" WORK SCHEDULE?
UNPAID
INTERMITTENT
YES
NO
SECTION 3. USAGE OF LEAVE CREDIT IS DETERMINED BY THE CBA (if applicable), CSU, FEDERAL & STATE LEAVE PROGRAMS/POLICIES
USING LEAVE CREDITS BELOW
ESTIMATED LEAVE ACCRUAL TOTALS AS OF
SICK LEAVE
VACATION (PER CBA & TITLE V)
PERSONAL HOLIDAY
HOLIDAY CREDITS/CTO
SICK LEAVE
VACATION
PERSONAL HOLIDAY
HOLIDAY CREDITS/CTO
SECTION 2. LEAVE REQUEST
SECTION 4. LEAVE PROGRAMS REQUIRE ADDITIONAL DOCUMENTATION AND MAY RUN CONCURRENTLY
PREGNANCY DISABILITY LEAVE
NON-INDUSTRIAL DISABILITY INS
CATASTROPHIC LEAVE DONATION PROGRAM
ORGAN DONOR LEAVE
EDUCATION CODE MATERNITY LEAVE (ECML)
NON-FML:
EXPANSION OF FML MILITARY
WOUNDED SERVICE MEMBER
QUALIFYING EXIGENCY
* If eligible, I will be placed on a PROVISIONAL FMLA for 15 days pending receipt of Certification of Health Care Provider.
* During my leave of absence, I understand that Human Resources will enter my eligible leave accruals into Absence Management for full & partial leaves.
* If leave of absence is approved, my compensation will be determined by the leave program(s) in Section 4.
* My health benefits, leave accruals, CalPERS service credit or other salary increases may be affected by the leave program and my Collective Bargaining Agmt.
I understand the terms and conditions of this leave that I am requesting.
Employee Signature
Date
EMPLOYEE NAME
FRESNO STATE ID#
* Prior to reporting to work, I must provide Human Resources with a medical release from my doctor if I am on a full or partial medical leave.
P 559.278.2032
Fax 559.278.4275
REQUEST FOR MEDICAL LEAVE
TO
COMBINATION OF PAID AND UNPAID
FAMILY&MEDICAL LEAVE (FML)&CALIFORNIA FAMILY RIGHTS ACT(CFRA)
SELF
FAMILY MEMBER
BIRTH OF CHILD
ADOPTION/FOSTER CARE
(As defined by FMLA)
If requesting to use sick leave accruals for family member care, the usage of sick leave must be
mutually agreed upon by Employee & Appropriate Administrator.
FACULTY Parental Leave (CFA ONLY- Article 23.4-23.6): Check one box
PARENTAL LEAVE (30 DAYS)
*LEAVE SHARING (Contact HR for eligibility - maximum 30 days)
Spouse/partner______________________________ Dept. ___________
to donate ____________days. *(Requires approval of Dean(s))
ACKNOWLEDGMENT OF LEAVE REQUEST
Department Chair/Manager
Dean/Department Manager
Print
Print
Signature
Signature
Date
Submitted by HR Analyst Date
Denied
11/2015
PARENTAL LEAVE (PER CBA)
Appropriate Administrator
WORKLOAD REDUCTION of 40% (6 WTUs) in lieu of Parental
leave. Working 60 % (9 WTUs) ________________ Semester.
Date
Date
Date
Approved
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Medical Leave Application Medical Leave Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 April 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document