UC Davis Health System Family and Medical Leave Kit
Human Resources supplies this kit to assist departments in handling the administrative aspects of a leave of absence under any of the following laws:
- Family and Medical Leave Absence under the Federal Family & Medical Leave Act (FMLA).
- Pregnancy disability Leave (PDL) under the California Fair Employment & Housing Act.
- Family and Medical Leave under the California Family Rights Act (CA-FMLA).
The kit contains all the forms needed to start, extend or terminate a leave of absence. However employees are not required to use these forms; anything that provides the same information is acceptable.
- Request for Leave of Absence/Intermittent Absence Form (Employee Completes): (Word PDF) Employee completes this form to request either an extended leave of absence or intermittent absences under FML. Employee turns in the form to his/her supervisor or manager and keeps a copy for his/her records:
Leave of Absence Form for Extended Time Off (Manager Completes)
- Leave of Absence Form for Intermittent Absences (Manager Completes)
Department Worksheet: A worksheet to assist departments in the completion of the Leave of Absence Form.
- Notice to Employees: The department uses this document to give the employee notice of his or her rights under the laws listed above.
Medical Certification Forms: A health care provider can use these forms to document the need for the leave
- Declaration of Relationship Form: For Family and In Loco Parentis Medical Leave Purposes.
- Return to Work Clearance: A health care provider can use this form to document that the employee is able to return to work.
- Intermittent FMLA/PDL Tracking: The department uses this form to document intermittent absences as permitted by the law.
- Leave of Absence Class Material (PDF).
- Kin Care Information: Frequently Asked Questions about Kin Care. (PDF)
- NEW Military Family Leave Entitlements: Fact sheet by Dept of Labor about the New FML Military Entitlement
Military Caregiver Leave and Qualifying Exigency Leave (PDF).
NOTE: The Leave of Absence Checklist, Department Worksheet, Medical Certification, Return to Work Clearance, and Intermittent FMLA/PDL Tracking Forms are to remain in the department.