Fillable Request For Leave Of Absence Procedures - Leav.Abs.Proc

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Request For Leave Of Absence Procedures - Leav.Abs.Proc

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Human Resources & Employee Relations
14000 Fruitvale Avenue
Saratoga, California 95070
OPERATIONAL PROCEDURES FOR A LEAVE OF ABSENCE
COMPLETE THE REQUEST FOR LEAVE OF ABSENCE FORM AND SUBMIT ANY REQUIRED
DOCUMENTS THAT ARE APPLICABLE TO YOUR LEAVE.
A. If leave is requested for your own serious health conditions, you must provide a Physician’s
Verification Form (see attached) from a health care provider stating:
a. the date the condition began.
b. the probable duration of the condition.
c. a statement that due to the serious health condition, you are unable to perform one or more
of the essential functions of your job.
B. If leave is requested for pregnancy disability, you must provide a Physician’s Verification Form
(see attached) from a health care provider stating:
a. the date the disability began.
b. the probable duration of the disability.
c. a statement that due to the disability, you are unable to perform one or more of the essential
functions of your job.
C. If leave is requested for the serious illness of a child, or for a serious health condition of a parent
or spouse, you must provide a Medical Certification Statement (see attached) from a health care
provider specifying all of the following:
a. the date on which the condition began,
b. the probable duration of the condition,
c. an estimate of the amount of time the health care provider believes you will need to care for
the individual,
d. a statement from the health care provider that the serious illness or health condition
warrants the participation of a family member.
D. If leave is requested for adoption, you must provide certification from the adoption agency
stating the date the adoption began.
E. If leave is requested by an employee to take a reduction in work hours, you must complete the
attached Leave of Absence Request Form.
Note: Please check with the Benefits Specialist regarding your benefits before submitting this form.
AFTER YOU HAVE COMPLETED THE LEAVE OF ABSENCE REQUEST FORM AND HAVE
ATTACHED ALL APPROPRIATE DOCUMENTS, FORWARD TO YOUR IMMEDIATE SUPERVISOR
WHO WILL THEN FORWARD TO HUMAN RESOURCES.
HR/ras/02-01-06
Human Resources & Employee Relations
14000 Fruitvale Avenue
Saratoga, California 95070
LEAVE OF ABSENCE REQUEST FORM
NAME: DEPARTMENT:
DATATEL ID #: CAMPUS:
Beginning Date of Leave: Ending Date of Leave:
CLASSIFIED ACADEMIC
Reason for Leave (Check one): PAID LEAVE UNPAID LEAVE
a.) Pregnancy Disability Leave (attach a copy of the Physician’s Verification Form).
b.) Bonding or adoption of a child, or the receipt of a child to foster care, within one year of such birth or
placement (for adoption, attach a copy of the certificate from the adoption agency).
c.) The employee’s own serious health condition that makes it impossible to perform essential job functions
(attach a copy of the Physician’s Verification Form).
d.) A serious health condition of an employee’s eligible child, spouse, parent or member of the immediate
household which requires the employee to care for the family member (attach a copy of the Medical
Certification Statement Form).
e.) Military Leave (attach a copy of the military orders).
f.) Other (specify below).
Explanation:
Note: If the employee’s leave of absence constitutes a reduction in FTE, then the employee shall be responsible for paying the
percentage (%) of reduction towards their benefits.
Employee must provide the Director of Human Resources fourteen (14) days notice of their intent to return to work. This
notice will include a statement from the physician affirming the worker’s ability to resume the duties of his / her job
description.
I concur with the terms and conditions of the leave and understand that it will be my obligation to return to District
employment on the working day following the ending date of the leave or the date as indicated on the medical release form. I
am aware that failure to return from leave may be construed as abandonment of the employee’s position.
Signature of Employee Date
RECOMMENDED NOT RECOMMENDED
Signature of Supervisor Date
Signature of Associate Vice Chancellor Date
HR/ras/01-24-06
Cc: Benefits, Supervisor, Employee
Human Resources & Employee Relations
14000 Fruitvale Avenue
Saratoga, California 95070
PHYSICIAN’S VERIFICATION FORM
is not physically able to work in his / her present position
(Patient’s Name)
effective through due to the following reason(s):
(Date)
(Date)
Print Name of Health Care Provider Signature
Date Phone Number State License Number
Please return this form to the Human Resources Department.
HR/ras/01-25-06
Human Resources & Employee Relations
14000 Fruitvale Avenue
Saratoga, California 95070
MEDICAL RELEASE
I authorize the release of any medical information necessary to process this request.
Patient’s Signature Date
MEDICAL CERTIFICATION STATEMENT
Name of Employee:
Is this Certification for the Employee or for the Ill Family Member?
Name of Ill Family Member (patient):
Date Condition Began: Date Condition Ended:
(or is expected to end)
Medical facts regarding the condition:
Explanation of extent to which employee is unable to perform the functions of his / her job:
Print Name of Health Care Provider Signature
Date Phone Number State License Number
Please return this form to the Human Resources Department.
HR/ras/01-25-06
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Completed 10 March 2020

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