FMLA Forms
FMLA Designation Form
Contacts:
Phone: (213) 241-3954
FAX: (213) 241-8993
TTY: (213) 241-6882
Office: 333 S. Beaudry Ave.
28th Floor
Los Angeles, CA 90017

Forms and Paperwork Required for an FMLA/CFRA Leave and/or Absence

In order for a leave and/or absence to be protected under FMLA/CFRA, employees need to give their Administrator or Supervisor certification from their (or their family member’s) health care provider. Exactly what paperwork is required depends on two factors:

(1) if you are a Certificated or Classified employee and

(2) if your absence is/will be intermittent or short term (less than 20 consecutive working days) or long term (21 or more consecutive  working days).

All employees are required to complete the Certification/Request of Absence for Illness, Family Illness, New Child (Form No. 60.ILL) whenever they are absent for either their own illness/ injury/medical appointment or that of a covered family member (even if the employee is on a long term leave).  This form is for payroll auditing purposes and is required for all illness related absences.

CERTIFICATION/REQUEST OF ABSENCE FOR ILLNESS, FAMILY ILLNESS, NEW CHILD (Form No. 60.ILL)

In order to document and recognize FMLA/CFRA absences, employee must respond to questions #5 and 6 on Form No. 60. ILL.  Failure to respond to these two questions could result in absences not being protected under FMLA/CFRA.

For FMLA/CFRA forms and Leave of Absence forms (for long term absences of 21 or more consecutive working days) please click on your appropriate employee type.

CERTIFICATED EMPLOYEES
(e.g. Teachers, Principals, School Psychologists/Counselors)

CLASSIFIED EMPLOYEES
(e.g. Office Staff, M & O Workers, Cafeteria Staff)


FORM FOR DESIGNATING FMLA/CFRA ABSENCES (Administrators/Supervisors Only)

When the Administrator or Supervisor has enough information to designate an employee’s absences as FMLA/CFRA protected, the Administrator or Supervisor must give the employee a Designation Letter (FMLA- 1).

Designation Letter (FMLA – 1)

For additional FMLA/CFRA forms and letters, please contact FMLA Programs at 213-241-3954.

ALL PAPERWORK PERTAINING TO AN EMPLOYEE’S FMLA/CFRA LEAVE OR ABSENCE SHOULD BE KEPT IN A CONFIDENTIAL FILE, SEPARATE FROM THEIR REGULAR PERSONNEL FILE.


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