LETTER TO EMPLOYEE TO INITIATE FMLA/CFRA LEAVE
Notice of FMLA/CFRA Eligibility, Rights and Responsibilities, and Designation of
The purpose of this letter is to notify you about your eligibility for Family Medical Leave Act
(FMLA) and California Family Rights Act (CFRA) leave.
A. Notice of Eligibility
On ________ you informed us of your need for a leave of absence beginning on ________ for
your own serious health condition. In general, to be eligible for FMLA/CFRA leave an
employee must have worked for an employer for at least 12 months, have worked at least 1,250
hours in the 12 months preceding the leave, and work at a site with at least 50 employees within
a 75-mile radius. This notice is to inform you that you are eligible for FMLA/CFRA leave.
Additional rights and responsibilities are described below.
B. Rights and Responsibilities for Taking FMLA/CFRA Leave
You are eligible for up to 12 weeks of unpaid leave in a 12-month period measured forward from
the date of your first FMLA leave usage. As explained above, you meet the eligibility
requirements for taking FMLA/CFRA leave. You have previously used _____ weeks of
FMLA/CFRA, and therefore, you have __________ weeks of leave available to you in the
applicable 12-month period. You will be required to use your accrued, unused paid time
off/vacation during your FMLA/CFRA absence.
Your health benefits will be maintained during this 12-week period under the same conditions as
if you continued to work. While on your FMLA/CFRA leave you will be responsible for
contacting _______ at ______ to make arrangements to continue to make your share of the
health insurance premiums in order to maintain health benefits while you are on leave. The
amount of your payment will be ________. You have a minimum 30-day grace period in which
to make premium payments. If payment is not made on time, your group health insurance may
be cancelled, provided we notify you in writing at least 15 days before the date your health
coverage will lapse, or, at our option, we may pay your share of the premiums during your
FMLA leave and recover these payments from you upon your return to work. If you do not
return to work following FMLA/CFRA leave for a reason other than: 1) the continuation,
recurrence, or onset of a serious health condition which would entitle you to FMLA leave; 2) the
continuation, recurrence, or onset of a covered service member’s serious injury or illness which
would entitle you to FMLA leave; or 3) other circumstances beyond your control, you may be
required to reimburse us for our share of the health insurance premiums paid on your behalf
during your leave.
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.P•A•S Rev. 03/11