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cal poly pomona


									                                                    Cal Poly Pomona
                                     Leave Of Absence Application
Side 1 of 2 (Please complete both sides)

                                             Section I - Employee Information
  Employee (Please print)                         Bronco Number                             Department

  Position Title                                                                            On-Campus Extension
                                                  E-mail Address
  Address (While on leave)
                                                                                            Telephone Number (While on leave)
  _______________________________________________________________________                   (_____)_______________________

  Current Status:                                            Collective Bargaining
                                                                                            Cell Phone Number (While on leave)
   Probationary                                             Identifier:
   Permanent                                                                               (_____)_______________________
   Temporary (Appt. Exp. Date:_____/______/_____)
  Print Department Chair/HEERA Manager’s Name:               Have you had any prior         If answer is yes, please indicate the CSU
                                                             employment with the            campus/State of California agency and
                                                             CSU/State of California?       the approximate length of service:
                                                                   Yes  No
  Application:              Reason(s) for Leave : (Check and complete all that apply)       Date leave starts         Date leave ends**
  (Check one)                   Own illness/injury (Not work-related)*                           /     /                  /    /

     New Leave                 Pregnancy Disability Leave (PDL)*                                /     /                  /    /

                                Care for family member with serious health condition*
                                                                                                  /     /                  /    /
                                 Relationship to employee:_______________________
     Extension of
  Previous Leave                Care for Newborn/Newly Adopted, or Newly Placed
  New return to work             Foster Child. Date of birth or placement (adoption/              /     /                  /    /
  date:                          foster care):  ____/_____/____
  ______/_____/_____            Military Leave (Attach orders)                                   /     /                  /    /

                               Other (Explain Reason Below)                                     /     /                  /    /
     Early Return
  New return to work        Reason for Leave (when “Other” is checked above): _______________________________________
  date:                     _________________________________________________________________________________
  ______/_____/_____        _________________________________________________________________________________

                            Last day worked: ______/_______/______ Return to work date: ______/_______/______

                             *Medical Certification is required and must be attached for all medical and family care leaves.
                            **Date leave ends refers to the last day on leave (day preceding the return to work).

  Type of Leave:              Full-time leave  Partial leave       (# of hours absent per week_______)           Intermittent leave

    Requested schedule (Required for partial or intermittent leave requests):____________________________________________


                                                 (Side 1 of 2)
                                           Section II - Family Medical Leave (FML)
Refer to this section if you have been employed by the California State University/State of California for at least twelve months
(Management/staff) or one academic year (Faculty), not necessarily continuously, and your leave is for any of the following reasons:
     You are unable to perform the essential functions of your own job because of your own serious health condition; or
     To care for your child after birth, or placement for adoption or foster care*; or
     To care for your spouse, son or daughter, or parent, who has a serious health condition.
Please read the FML information provided in the instruction sheet for this form. Leaves for FML purposes, paid or unpaid, will be
counted toward the 12-week FML entitlement.
*FML after the birth or placement of a child must be initiated within twelve months beginning with the birth or placement
Insurance Continuation During FML:
If you are currently enrolled in medical, dental and/or vision insurance through the University, please indicate below if you
request Cal Poly Pomona to continue to pay the monthly premium(s) during your leave for FML purposes. Upon your return
to work, the University will collect your share of the premium(s), if any, via payroll deduction. If you do not return to work,
the CSU will require you to repay the full premium(s), including the employer’s share, unless you do not return because of
your own serious health condition or due to circumstances beyond your control. Note: If you do not continue the insurances
during FML, please contact Human Resources/Benefits for information about reinstating your benefits.

Continue these insurances (Circle yes or no for each plan):             Medical (Yes/No)               Dental (Yes/No)      Vision (Yes/No)

                                  Section III - Employee Leave of Absence Certification

My signature below is to certify that the information relevant to this application for leave is accurate and truthful. I also understand
that any misrepresentation on my part may be cause for denial or rescission of the leave, or dismissal.

_______________________________________________________                             ________________________
Employee’s Signature                                                                          Date

                                    Section IV – Eligibility/Entitlement Determination

Based upon the information provided in this leave request, and any attached supporting documentation, it is hereby determined by
the HR/Payroll Leave Coordinator that this leave is:
□ An entitlement Comments: ______________________________________________________________________________
□ Not an entitlement - approval/denial of leave request to be made by appropriate manager(s) based upon operational needs of the
□ Other ________________________________________________________________________________________________

_______________________________________________________                             ________________________
HR/Payroll Leave Coordinator                                                                  Date

                                              Section V - Line Organization Review
Line Organization Signatures: (If leave or any part of leave requested is denied, please state reason and forward request through the line
organization for review. Use additional sheets as necessary to explain the denial.)

HEERA Supervisor or Department Chair:  Mandated  Approved  Denied      Date:                         Reason/Comments:

HEERA Manager/Dean:                 Mandated  Approved  Denied         Date:                         Reason/Comments:

Vice President/President:           Mandated  Approved  Denied         Date:                         Reason/Comments:

Human Resources Review:            Mandated  Approved  Denied          Date:                         Reason/Comments:

Form Distribution: Employee, Human Resources, Payroll, HEERA Manager/Dean              (Side 2 of 2)                                    Rev 5/2004

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