Fillable MedicalLeaveApplication Form Medical Leave Application

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

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MedicalLeaveApplication Form Medical Leave Application

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

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  • 51 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

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

BROWSE CALIFORNIA STATE UNIVERSITY, FRESNO FORMS

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(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
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
MEDICAL LEAVE APPLICATION
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
Assoc. Vice President of HR
Date
Approved
Denied
HR MGR - BENEFITS
6/5/14
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
✔
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MedicalLeaveApplication Form Medical Leave Application

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Completed 17 April 2020

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