Leave Of Absence Application


Pregnancy Disability Leave – California
(Please print)
Work Ext.________
Supv's Ext.
Job Title
Home Phone
Home Address
First day out
Return to work date
1. Policy Summary
Employees who are disabled on account of pregnancy, childbirth or related medical
conditions are entitled to an unpaid leave of absence (LOA). Time off needed for prenatal
care, severe morning sickness, doctor ordered bed rest, childbirth and recovery from
childbirth will all be counted against an employee’s pregnancy disability leave entitlement.
2. Procedures for Completing the LOA Application
At least 30 days prior to your anticipated leave start date, complete and sign this application
form and submit it to your supervisor. The application form should then be forwarded to
Human Resources at SP211, at least two weeks prior to the leave start date except in cases
of a bona fide emergency situation.
3. Duration of Leave
Pregnancy-related disability leaves of absence are for the period of disability up to a
maximum of four (4) months.
Such leave will be counted as part of the employee's
entitlement to leave under the California Pregnancy Disability Leave law.
4. Certification Requirement
You must provide medical certification from your physician. This certification should state
the probable duration of the condition and that due to the condition, you are unable to
perform one or more of the essential functions of your position. If there is a change to the
approved return to work date, you must provide additional medical certification indicating the
continued need for leave and the new probable return to work date. An extension of leave
must be requested in writing and authorized as an extended LOA.
Effective: 01/01/2017


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