Date:



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To: Central Benefits Office - Campus Human Resources

10920 Wilshire Blvd. Suite # 200

Phone: 310-794-0830

Fax: 310-794-0835, or

Email:      @chr.ucla.edu

From:      /     

Re: Unpaid Leave of Absence Notice

Sections 1 to 5 of this Notice must be completed and immediately sent to the Central Benefits Office whenever an employee goes on an UNPAID leave of absence. Once received, the Central Benefits Office will send a leave packet. UCPath will send a letter with instructions about how and where to make direct payment of insurance premiums for any benefit plans an employee wishes to continue during all unpaid leaves of absence.

|Section 1 - Personal Information |

|Employee Name:       |Employee ID #:      |

|Home Department Name:      |Home Department #:      |

|Employee’s home address:       |Employee’s phone #:      |

|Employee’s personal email address:       |

|Is employee normally scheduled to work a full 12 months each year? yes |Before this leave of absence, was employee working: |

|no |full-time part-time |

|If no, give periods of employment: | |

| |If part-time, was the reduction due to disability? |

|From       to       |yes no |

|Section 2 – Indicate Type of Leave (this list is not all inclusive) |

| |Attach Copy of: |

|Check One | |FMLA Letter |Job Description |

| |Employee Disability Unpaid Leave |Yes |Yes-Required |

| |Pregnancy Disability Unpaid Leave |Yes |Yes-Required |

| |Work Incurred Injury - Workers’ Compensation |Yes |Yes-Required |

| |Last Day of 80% Extended Sick Leave:       | | |

| |Furlough |No |No |

| |Temporary Layoff |No |No |

| |Personal Leave |No |No |

| |Professional Development Leave (faculty only) |No |No |

| |Military Leave |No |No |

| |Postdoc Unpaid Leave |No |No |

| |Other Leave without pay       (indicate type) | | |

| |Benefits Bridge – Non-Senate Faculty Only – Unit 18 |Re-employment Commitment Letter |

| | | |

Leave of Absence without pay Notice – Page 2

|Section 3 – Leave of Absence Dates |

| | |Date: (month/day/year) |

|1. |Last Day Actively at Work: |      |

| |Number of hours worked: |      |

|2. |Did employee receive ANY pay AFTER last day worked (#1 above)? yes* | |

| |no | |

| | | |

| |*If yes, indicate type and dates here: | |

| |Sick |From       thru      |

| |Vacation |From       thru      |

| |Comp Time |From       thru      |

|3. |Last Day on Pay Status: |       |

|4. |Unpaid Leave of Absence Begin Date |      |

|5. |Anticipated Return to Work/Pay-Status Date |      |

|6. |Separation Date, if applicable |      |

|Section 4 – FMLA Information |

|1. |Is any portion of this leave an approved FMLA? | yes no |

|2. |If yes, provide FMLA dates for this leave of absence: |First day of FMLA:       |

| | |First day of Unpaid FMLA:       |

| |      |(this date will be equal to or later than Section 3.4 above) |

| | |Last day of FMLA:       |

|Section 5 – Certification & Authorization |

|I certify this leave has been approved and recorded on-line in the PSFT System on this date: ___________ |

|Comments: |

| |

| |

|Authorized Initiator/Approver:       |Department Name:       |

|Campus phone #:       |Department Mail Code:       |

|Date:       |Department Fax #:       |

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Campus Human Resources

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