INSTRUCTIONS FOR COMPLETING "LEAVE OF ABSENCE DESIGNATION" (For Office Use Only --Do Not Staple Or In Any Way) Attach These Instructions To The "Leave Of Absence Designation" Form
This form should be completed with the employee immediately upon the employee's return to work following leave and placed in the employee's personnel file for future reference. FMLA, CFRA, sick, vacation, workers' compensation disability , and pregnancy disability leaves can run concurrently. State and federal family and medical leaves run concurrently and employees are entitled to a maximum combined total leave of 12 workweeks per 12-month period. All accrued paid sick leave and vacation may also be concurrently charged with an employee's family and medical leave. Employees on workers' compensation disability leave because of a "serious health condition" should also have their family and medical leave entitlements charged. Note, however, that California law expressly provides that leave for pregnancy related disabilities does not run concurrently with state family and medical leave. Employees thus cannot be charged against their state family and medical leave entitlement for taking a pregnancy disability leave and vice versa. Employees on pregnancy disability leave, however, can and should be concurrently charged with taking medical leave under the federal FMLA. Further, [Company] should continue to provide health insurance as if the employee had continued working for the first 12 workweeks of the California pregnancy disability/FMLA leave. Doing so will enable [Company] to limit employees to 12 workweeks of continued health insurance coverage per 12-month period. Otherwise, 12 workweeks of continued health insurance coverage must be provided for pregnancy disability leave and for any subsequent family and medical leave under state law. The regulations to California's family and medical leave Act mandate that the 12-month period begin on the date an employee first uses FMLA leave, with successive 12-month periods commencing on the date of the employee's first use of FMLA leave after the preceding 12- month period has ended. Retain the signed Leave of Absence Designation form in the employee's personnel file as a record of the leave and for future reference.
P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this form, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained.
[COMPANY] LEAVE OF ABSENCE DESIGNATION
Employee: ____________________________________ Position: __________________________________
Leave taken from ________________________________ , through and including __________________________ Leave Designated: (Check as many as applicable) ٱ ٱ Sick Leave Federal Family and Medical Leave (Maximum Duration - 12 workweeks) California Family Rights Act Leave (Maximum Duration - 12 workweeks) Workers’ Compensation Disability Leave (Maximum Duration - Indefinite) Pregnancy Disability Leave (Maximum Duration - 4 months) Vacation Leave Personal Leave Funeral or Bereavement Leave (Maximum Duration of Paid Leave - ____ days) Jury Duty Leave (Maximum Duration of Paid Leave - ____ days) (Maximum Duration of Unpaid Leave - Indefinite) Witness Duty Leave (Maximum Duration of Paid Leave - ____ days) (Maximum Duration of Unpaid Leave - Indefinite) Military Leave (Active and Reserve Status) (Maximum Duration - Indefinite) OTHER LEAVE (Specify): ____________________ Amount Of Time Charged:
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P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this form, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained.
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_________________________________________________ Employee’s Signature
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Department Head
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_________________________________________________ Human Resources Director
P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this form, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained.