Date Name Address Dear Employee Name Thank you for the information you provided advising me that your doctor has certified you as disabled effective date In addition to by oot20032

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									[Date]


[Name]
[Address]



Dear [Employee Name]:

Thank you for the information you provided advising me that your doctor has certified
you as disabled effective [date].

In addition to the university’s medical leave, you also may be eligible for unpaid leave
under the Federal Family and Medical Leave Act (FMLA) and California Family Rights
Act (CFRA). Eligibility for these leaves requires that you have been employed by the
university for at least 12 months by the start of the leave and have worked 1,250 hours
during the 12 months preceding the leave.

FMLA and CFRA both provide an employee suffering from a certified serious health
condition with up to 12 weeks of unpaid leave. These 12 weeks will run concurrently
with the university’s medical leave. I am writing to inform you that, contingent on
certification of your eligibility for such leave, the university is placing you on
FMLA/CFRA leave effective[date] for [up to 12] weeks or until you are no longer
certified as disabled, whichever comes first.

Your leave may qualify for disability insurance payments. If you participate in the
university’s disability plan, contact the university’s disability claims administrator,
Sedgwick CMS. You may file your claim via telephone by calling (800) 495-2315
between the hours of 6:00 a.m. and 4:45 p.m. Pacific time. Sedgwick will send you the
forms required for your claim for disability benefits. If you participate in the state
disability plan, contact the State of California Employee Development Department
nearest your home.

While you are certified as medically disabled, your position at the university is protected
for up to four months within a rolling 12-month period. For additional information about
your employment rights while on medical leave, please refer to the university’s Medical
Leave Policy. Your failure or inability to return to work upon the expiration of any
approved leaves or extension thereof may result in termination. It is your responsibility
to keep me informed of your status and requests for extension of your leave and to do so
in writing. You also must submit (to your disability plan administrator, if you qualify for
disability insurance payments; to me, if you do not) required medical certification
supporting your leave and requests for extensions in a timely manner.

If you have any questions or need additional information, please call me at [supervisor
telephone]. Questions about FMLA and CFRA leave should be directed to the
university’s Leave Coordinator, Leticia Molina, at (213) 821-8120.] [For employees on
the University Park campus: Any questions you have regarding your health benefits
during your leave should be directed to Kevin Johnson, Office of Benefits Administration
at (213) 821-8112. [For employees on the Health Sciences campus: Any questions you
have regarding your health benefits during your leave should be directed to Maria
Chacon, Director of Personnel Services on the Health Sciences campus at (323) 442-
1010.] The university Family Care Medical Leave and Medical Leave of Absence
policies are available on the USC Web site (www.usc.edu/policies).

Sincerely,


[name]
[title]

cc: [Home Department Coordinator]

								
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