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					                                     UCLA Healthcare Human Resources
                           LEAVE OF ABSENCE NOTIFICATION (LOAN)
                                                  (Rev. 03/21/07)

When appropriate, an employee should request a leave of absence at least thirty (30) days prior to
commencement of the begin date of the leave.

This form must be completed and e-mailed to the Central Healthcare HR Benefits Team assigned to the
department in which the employee works as soon an employee’s supervisor approves a leave of absence. Once
received, the HR Benefits Team will mail to the employees home address, an information packet including a letter
with instructions for continuing health insurance coverage and making direct payments to the HR Benefits Office.
The information packet for employees on a pregnancy and/or disability leave will also include instructions on filing
a disability claim with Liberty Mutual. A department’s failure to complete this form and e-mail it to HR Benefits in a
timely manner will cause a delay in the employee receiving an instruction packet as well as disability income, if
applicable, from Liberty Mutual.

DATE:                            Initial Leave          Extension              Revision/Correction

                                   PART 1 – Employee Information
                                (TO BE COMPLETED BY DEPARTMENT REP)
Employee Name: (Last, First, MI)              Employee ID#:                   Department:

Payroll Classification:                       Title Code:                    Work Shift:
                                                                               8 hr      10 hr      12 hr
Is employee normally scheduled to work a full 12 months each year?         Yes    No
If no, when is the employee scheduled to work?
Before this leave of absence, the employee was working:    Full Time        Part Time
If part-time, was the reduction due to disability? Yes     No

                                PART 2 – Type of Leave of Absence
                                (TO BE COMPLETED BY DEPARTMENT REP)
Check One                    Leave of Absence
               *Employee Disability
               Please attach job description
               *Pregnancy Disability
               Expected Due Date:           (Attach FMLA Letter that was issued to employee)
               Health care for spouse, domestic partner,
               child, or parent
               Adoption/Foster Care
               Birth and care of newborn child
               *Work Incurred Injury - Workers’ Comp        Workers’ Comp Claim Filed:
               Last Day of Extended Sick Leave (80% ESL):       Approved     Pending

                                                                         Option 1       Option 2     Option 3
               Please attach job description
               Temporary Layoff

                                                     Page 1 of 3
                                       UCLA Healthcare Human Resources
                             LEAVE OF ABSENCE NOTIFICATION (LOAN)
                                                     (Rev. 03/21/07)

    *Briefly describe present job duties (e.g., routine office, laborer, custodial, patient care,

                      PART 3 – Leave of Absence and Time Certification
                                 (TO BE COMPLETED BY DEPARTMENT REP)
Last Day Actively Worked:
Number of Hours Worked on Last Day Worked:
Last Day on Pay Status Using Sick Leave:
Last Day on Pay Status Using Vacation Leave:
Last Day on Pay Status Using Comp Time:
Leave of Absence Without Pay Begin Date:
Anticipated Return to Work/Pay Status Date:
(This includes return to pay status by use of
vacation leave)
Separation Date, if applicable

                                       PART 4 – FMLA Information
                                 (TO BE COMPLETED BY DEPARTMENT REP)
Is any period of this leave of absence approved as FMLA?     Yes   No
If yes, provide period designated as FMLA:      Leave Begin:     Leave End:
Period of FMLA with Pay:                        Leave Begin:     Leave End:
(This includes use of vacation and sick leave)
Period of FMLA without Pay:                             Leave Begin:             Leave End:

                       PART 5 – University Contribution Indicator (UCI)
                                 (TO BE COMPLETED BY DEPARTMENT REP)
This section must be completed only for FMLA, Disability, Furlough and Temporary Layoff
leaves of absence in order for the University Contributions toward medical, dental and vision, if
applicable, to be applied in accordance with policy and charged to the appropriate department
                     Benefit Account(s) to be Charged While Employee is on Leave Without Pay
Up to three (3) benefit accounts may be charged while an employee is on leave of absence. Charges will be prorated
based on percent entered in last column. If only one account is to be charged, only complete the top line and enter 100%.
 Location Code             Account               CC                  Fund              Project               Percent

                                                        Page 2 of 3
                                    UCLA Healthcare Human Resources
                          LEAVE OF ABSENCE NOTIFICATION (LOAN)
                                                (Rev. 03/21/07)

                         PART 6 – EDB Certification & Authorization
                              (TO BE COMPLETED BY DEPARTMENT REP)
I certify that the leave of absence has been approved and that the leave periods are properly recorded in EDB
as appropriate. Date Leave of Absence entered in EDB:
EDB Preparer:                                                Department:
Phone extension:                                             Department Fax:          Mail Code:
Leave of Absence Approved by:                                Phone extension:

                                                   Page 3 of 3