Leave of Absence

How to Request FMLA/CFRA

1. Complete the Request for FMLA/CFRA
2. Take the appropriate Physician Certification form to the doctor to complete. Note: Some doctors, clinics, and/or hospitals prefer to use their own standard form. We will accept these forms in lieu of our form, provided that the medical note contains all of the required information.
   1. If the leave is for your own illness, use the Physician Certification - Employee
   2. If the leave is for you to care for a family member who is ill, use the Physician Certification - Family Member
3. Complete the PHI Authorization Note: The form must be signed and completed by the person whose medical information is being received.
   1. If the leave is for your own illness, complete the form yourself.
   2. If the leave is for you to care for a family member who is ill, ask the family member to complete the form. Note: If family member is a minor the form must be completed by the parent/guardian.
4. If you anticipate requiring Short Term Disability (you anticipate running out of leave balances prior to returning to work), please submit a memo to the HR Director requesting STD payments when your balances have been exhausted.
5. If you plan on requesting extended time off, beyond the 12 weeks covered by FMLA/CFRA, you should submit a memo to your Department Head and HR requesting an extended medical leave of absence.
6. Give the following completed documents to your Department Head for Approval:
   1. Request for FMLA/CFRA
   2. Memo requesting an extended medical leave of absence (if applicable).
7. After your Department Head approves your leave, forward all paperwork to the Human Resources Department for final acceptance.
8. If requesting Intermittent Leave, make sure HR receives copies of your time cards for tracking purposes.