Leave of Absence | Human Resources

Forms
Sample Cover Letters
Catastrophic Leave Forms
Academic Student Employees (ASE)

Leave of Absence Forms

Certification of Health Care Provider for Employee’s Serious Medical Condition	Certification of Health Care Provider for Family Member’s Serious Medical Condition
Certification of Health Care Provider for Employee’s Pregnancy Disability	Certification for Military Caregiver Leave (Leave Due to Serious Injury or Illness of Covered Service Member
Certification for Qualifying Exigency Leave - Leave Arising Out of the Active Duty or Call to Active Duty of a Covered Military Member	Leave of Absence Request Form
Designation Notice	Exempt Employee Workweek Agreement for FML Leaves Taken on a Reduced Schedule or Intermittent Basis
Return to Work Certification	Parental Leave Certification
Pregnancy Disability Leave Certification	Declaration of Relationship
Notice of Eligibility and Rights & Responsibilities Form	Family and Medical Leave Fact Sheet
Return from Leave Health Benefits Reinstatement Form	Employee Rights under the Family and Medical Leave Act (April 2016)

Sample Cover Letters

Certification and/or Declaration of Relationship Not Received	Family Medical Leave Certification Incomplete or Insufficient
Return to Work Certification	Designation Letter for all but Combined PDL and Parental Leave
Designation Letter for Approved Combined PDL and Parental Leave	Employee Not Family Medical Leave Eligible
Employee FML Eligible but Leave Entitlement Exhausted	Employee Family Medical Leave Eligible for Employee’s Serious Health Condition Coming Soon
Employee FML Eligible for Family Member’s Serious Health Condition	Employee FML Eligible Combined PDL and Parental Leave
Employee Family Medical Leave Eligible Pregnancy Disability Leave Only	Employee Family Medical Leave Eligible Parental Leave Only
Employee Not FML Eligible Pregnancy Disability Leave Only	Employee Family Medical Leave Eligible But Leave Entitlement Exhausted Pregnancy Disability Leave only
Letter for Change in End Date of Pregnancy Disability Leave	Parental Leave Only Confirmation Letter
PDL Only Confirmation Letter for not FML Eligible	Medical Recertification for Family Medical Leave

Catastrophic Leave Forms

Catastrophic Leave Donation Form	Catastrophic Leave Request Form
Wildfire Catastrophic Leave Donor Form

Academic Student Employees (ASE)

ASE Contract - Article 18 - Leaves	ASE Leave Request Form
ASE Leave Department Check List	ASE Medical Certification Form
ASE Certification of Health Care Provider for Pregnancy Disability Leave	Declaration of Relationship Form
ASE Return to Work Certification Form	ASE Leave Approval Letter
ASE Leave Approval Letter for Long Term Childbearing Leave	Sample Letter to ASE re. Leave Request & Required Documents