EMPLOYEE NAME: (LAST, FIRST, MIDDLE) BARGAINING UNIT EMPLOYEE ID #
CLASSIFIED
ACADEMIC
LOCATION NO. LOCATION NAME: POSITION TITLE:
START DATE END DATE NO. OF DAYS NO. OF HOURS TIME (FROM – TO)
Type of Leave [check appropriate box] and provide details as indicated. Only the employee should complete the form.
Any changes should be initialed by the employee.
Vacation
Change to previously submitted request? Y N
Previous Dates:
Sick Leave** (may need verification from physician)
Faculty Monthly Faculty Hourly
Family Necessity Leave** Care for unit member's sick child, parent, spouse or domestic partner.
Leave, per calendar year, taken from Accrued, Full Salary Sick Leave only.
Personal Necessity Leave ** (may qualify for FMLA depending on circumstances)
Leave, per fiscal year, taken from Accrued, Full Salary Sick Leave only.
Comments/Reasons:
Relationship:
Reason (if required by agreement)
Comp Time
Available balance Remaining Balance
(for office use only)
SHORT-TERM LEAVE (NOT TO EXCEED 30 CALENDAR DAYS)
(paid, unless otherwise indicated)
Personal Business w/Pay
Personal Business w/out Pay** (may qualify for FMLA depending on circumstances)
Adoption/Paternity/Parental Leave **
w/pay (One day paid leave)
w/out pay (not to exceed 30 days)
Bereavement Leave -- (indicate # of travel miles
)
Short-Term Military Leave (not to exceed 30 workdays)
Court Appearance (other than litigant)
Jury Duty
Comments/Reasons:
Relationship:
Attach Orders
Attach supporting documents
LONG-TERM LEAVE (In excess of 30 CALENDAR DAYS)
(unpaid unless otherwise indicated)
Health Leaves - including leave due to pregnancy**
Family/Parental ** ( not qualifying for FMLA/CFRA)
Professional Study Leave
Service to Other Public Agencies & Institutions
Long-Term Military Leave - more than 30 workdays per college year (First 30 days paid)
Other (specify reason) - at Chancellor's discretion
Comments/Reasons:
Relationship:
Attach Materials Outlined in Agreement
Attach Orders
Specify reasons:
OTHER LEAVE OF ABSENCE
On The Job Injury/Industrial Accident **(requires physician's signature below)
Employee Organization Leave
Union-Paid Release Time
District Off-site Activity (District interviews, workshops, staff development meetings)
Date of Injury:
Name of Organization:
Identify Union:
Identify District Activity:
GENERAL INFORMATION – FMLA/CFRA
Family Medical Leave Act (FMLA)/California Family Rights Act (CFRA) **
Birth of a child/Care of newborn Date of Birth
Care for employee's parent, child, spouse or domestic partner
Adoption, placement or Foster care (with employee) Date of Adoption
Serious health condition of employee (Note: CFRA does not include pregnancy or related medical conditions within
definition of serious health condition.)
GENERAL INFORMATION – FMLA/PDL
Family Medical Leave Act (FMLA)/Pregnancy Disability Leave
(PDL)**
Pregnancy that makes absence from work medically necessary
Physician’s Certification: I certify that the above named person was unable to work during the above period.
PHYSICIAN’S SIGNATURE LICENSE NO. DATE
REQUEST FOR LEAVE OF ABSENCE
SAN DIEGO COMMUNITY COLLEGE DISTRICT
INSTRUCTIONS: PLEASE PREPARE ONE COPY AND SUBMIT TO YOUR SUPERVISOR AND/OR MANAGER FOR CONSIDERATION.
IMPORTANT: NOT ALL LEAVES ARE AVAILABLE TO ALL EMPLOYEES
REFER TO APPROPRIATE BARGAINING AGREEMENT/HANDBOOK FOR INSTRUCTIONS AND REGULATIONS
**NOTIFICATION: THIS LEAVE CONSTITUTES NOTIFICATION FOR FMLA AND/OR CFRA QUALIFYING EVENTS, PROVIDED THE EMPLOYEE IS QUALIFIED. PLEASE BE ADVISED THAT THE
LEAVE WILL RUN CONCURRENTLY WITH ANY AVAILABLE FMLA AND/OR CFRA LEAVE. SEE REVERSE FOR QUALIFYING REQUIREMENTS.
EMPLOYEE’S SIGNATURE DATE MANAGER’S/SUPERVISOR’S SIGNATURE DATE
(Please read the notice on page two of this form)
(For Long-term Unpaid Leave of Absence for “Other”) CHANCELLOR’S SIGNATURE DATE
Distribution: ORIGINAL: TIMEKEEPER PHOTOCOPY: SUPERVISOR PHOTOCOPY: EMPLOYEE
RQABS-Page 1 Feb. 29, 2008
Print Form
NOTICE TO EMPLOYEES REQUESTING FAMILY AND/OR MEDICAL LEAVE OF
THEIR SPECIFIC RIGHTS AND OBLIGATIONS
[Refer to your appropriate bargaining agreement/handbook for more detailed
instructions.]
1. In order to qualify for Family Medical Leave Act and/or the California Family Rights Act you must (a)
have been employed by the District for at least 12 months and have worked a minimum of 1250 hours
of service during the 12-month period immediately preceding the commencement of the leave. NOTE:
The District has adopted the “rolling 12 month period” for determining eligibility. This means that the
District will measure back 12 months from the date of the qualifying event.
2. Any District-approved leave of absence that you take, paid or unpaid, that is FMLA/CFRA qualifying will
run concurrently with the leave provided under your annual 12-week federal Family Medical Leave Act
(“FMLA”) entitlement and your annual California Family Rights Act (“CFRA”) entitlement. Hereinafter
this notice shall refer to both leaves as FMLA. EXCEPTION: Female employees are allowed up to 28
weeks (FMLA/CFRA 12 weeks plus PDL 16 weeks) for reasons of pregnancy, childbirth or related
medical conditions. Unit members wishing to take FMLA/PDL must provide the District with at least
thirty (30) days advance notice before the leave begins if the need for leave is foreseeable.
3. If you are requesting federal FMLA leave due to your own serious health condition or a serious health
condition of a family member, you must provide a medical certification regarding the nature of the
illness with submission of this form.
4. You are required to provide re-certification of the serious health condition every 30 days or, under
certain circumstances, before 30 days. Failure to provide a medical certification may result in denial of
your leave or the continuation of your leave until the certification is provided.
5. Medical certification need not identify the serious health condition but shall contain: (a) date, if known,
on which the serious health condition began; (b) probable duration of the condition; (c) an estimate of
the amount of time which the health care provider believes the employee needs to care for individual
requiring care; and, (d) a statement that the serious health condition warrants the participation of the
employee to provide care during a period of treatment or supervision of the child, parent or spouse. If
the medical certification of the serious health condition is for the employee, the certification shall also
include whether the employee is able to work at all or is unable to perform any one or more of the
essential functions of his or her position.
6. You may be required to provide a fitness-for-duty certification before you will be restored to employment.
7. You may be required by the SDCCD to substitute accrued vacation or other paid leave in place of your
FMLA leave if you are eligible for the paid leave according to your bargaining agreement. Such paid
leave will be counted against your FMLA entitlement.
8. You are entitled to restoration after FMLA leave to the same or equivalent job upon return from leave.
However, after your FMLA leave has been exhausted, if you continue on some other form of unpaid
leave, you may not be entitled to be restored to your position.
9. If applicable, you will be required to continue paying your share of your regular health insurance
premiums to maintain your health benefits during FMLA unpaid leave. The Benefits Office at the
inception of your FMLA will bill you. If your health insurance is District paid, you will continue to be
covered during FMLA unpaid leave.
10. You may be liable for the payment of health insurance premiums paid by the SDCCD during your
FMLA leave if you fail to return to work after taking FMLA leave. If payment is required the Benefits
Office will bill you.
RQABS-Page 2 Feb. 29, 2008