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Human Resources

Human Resources

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 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



  • 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.