City Of Milpitas Request For Family Medical Leave (Fmla)/ California Family Rights Act (Cfra)
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1CITY OF MILPITAS
REQUEST FOR FAMILY MEDICAL LEAVE (FMLA)/
CALIFORNIA FAMILY RIGHTS ACT (CFRA)
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) and/or the California Family Rights Act (CFRA) for up to 12 weeks of
unpaid, job-protected leave for certain family and medical reasons, and up to 26 weeks of unpaid, job-protected leave in a 12-month period to care for a
covered family member who was seriously ill or injured during their active military service.
To be eligible for FMLA/CFRA leave the employee must have been employed for at least 12 months; and have worked at least 1,250 hours during the 12
months prior to the commencement of leave. Employees are expected to give as much advance notice as possible when requesting FMLA/CFRA leave
and to make all reasonable efforts to minimize the disruption caused by their absence. Employees are required to substitute any available accrued paid
leave for any part of the applicable leave provided under the Family Medical Leave Act.
A.
EMPLOYEE INFORMATION
Employee Number
Employee Last Name
Employee First Name
Department
Home Address
Telephone
B.
LEAVE INFORMATION
Action
Leave Type
Leave Time Base
Leave Credits
Will you be using leave credits?
New
Birth or Placement of a
Continuous leave under
Child for Adoption/Foster
care of a licensed
Yes
Change
Care
practitioner during a
No
Cancel
Due Date:_________
prolonged period of
Please list the order in which to
incapacity or
take leave balances. Note: Sick
convalescence due to
FML Self- Employees Own
Leave will be exhausted first
Personal Illness or Serious
catastrophic illness
Health Condition
Intermittent leave or
__1__ Sick
reduced work
schedules. Attach
____ Vacation
FML Family
requested schedule and
Relationship:__________
provide time cards to
____ Comp Time
HR.
Care for Covered Service
The employee is required to
____ Floating Holiday
Member
furnish a written statement from
Relationship:____________
the licensed practitioner to
substantiate the need for
Qualifying Exigency for
continuous or intermittent leave
Military Family Leave
and whether leave will be taken
Relationship: ___________
as needed or on a set schedule.
Dates for Leave (please specify month, day, year)
Short Term Disability (STD)/Catastrophic Leave (Cat Leave)
Date From:
Will you be applying for STD
Yes (must exhaust all
No
leave credits)
Date Through and Including:
Will you be applying for Cat Leave
Yes (must exhaust all
No
leave credits)
Expected Return to Work Date:
C.
EMPLOYEE CERTIFICATION AND ACKNOWLEDGEMNT OF LEAVE DATES
This is to certify that the information provided here is accurate and to the best of my knowledge
_______________________________________________
___________________________________________
Employee Signature
Date
D.
APPROVALS
_______________________________________________
___________________________________________
Department Approval
Date
_______________________________________________
___________________________________________
Human Resources Approval
Date
HR Use Only
_______ Hours Worked per Week
_______ Hours Worked Last 12 Months _______ FMLA Hours Used Last 12 Months _______ FMLA Hours Remaining
_______ Approval/Denial Letter Sent
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