Archdiocese Of Los Angeles Family And Medical Leave Forms Page 13


Form C
Archdiocese of Los Angeles
Family and Medical Leave
Designation Notice
Employee’s Name ________________________ Location _____________________ Date _______
We have reviewed your leave of absence request that you provided on _________(date) and decided that:
Your FMLA leave request is approved. All leave taken for this reason will be designated as
FMLA leave.
If you take leave, as requested, from ______________(date) to _______________(date),
then _____________ (hours, days, weeks, or months) will be counted against the maximum
FMLA leave available to you. Please advise your supervisor of any changes in your
scheduled leave dates.
You may use paid leave (vacation, sick pay) or apply for disability benefits, where applicable
per Archdiocesan leave policy, but this paid leave will count against your FMLA leave
In order to return to work, all employees returning from medical leave must present a
doctor’s note fully releasing them to return to work. If your doctor releases you to return to
work with any restrictions, a decision about your return to work will be evaluated based on
the list of essential job duties. You must present the doctor’s full release confirming your
fitness for duty and ability to perform the essential job functions before you can return to
Additional information is needed to determine if your FMLA request can be approved,
specifically: _________________________________________________________.
Your FMLA Leave Request is not approved because:
The FMLA does not apply to your leave request.
You have exhausted all FMLA leave available to you within the last 12 months.
Designation Authorized by: ______________________ Title: _________________________________
Location: ____________________________________ Date: _________________________________
Revised 2013


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