LEAVE OF ABSENCE NOTIFICATION - UCLA Health
When appropriate, an employee should request a leave of absence at least thirty (30) days prior to commencement of the begin date of the leave.
This form must be completed and e-mailed to the Central Healthcare HR Benefits Team assigned to the department in which the employee works as soon an employee’s supervisor approves a leave of absence. Once received, the HR Benefits Team will mail to the employees home address, an information packet including a letter with instructions for continuing health insurance coverage and making direct payments to the HR Benefits Office. The information packet for employees on a pregnancy and/or disability leave will also include instructions on filing a disability claim with Liberty Mutual. Failure to complete this form and e-mail it to HR Benefits in a timely manner will cause a delay in the employee receiving an instruction packet as well as disability income, if applicable, from Liberty Mutual.
DATE: Initial Leave Extension Revision/Correction
|PART 1 – Employee Information |
|(TO BE COMPLETED BY DEPARTMENT REP) |
|Employee Name: (Last, First, MI) |Employee ID#: |Department: |
| | | |
|Payroll Classification: |Title Code: |Work Shift: |
| | |8 hr 10 hr 12 hr |
|Is employee normally scheduled to work a full 12 months each year? Yes No |
|If no, when is the employee scheduled to work? |
|Before this leave of absence, the employee was working: Full Time Part Time |
|If part-time, was the reduction due to disability? Yes No |
|PART 2 – Type of Leave of Absence |
|(TO BE COMPLETED BY DEPARTMENT REP) |
|Check One |Leave of Absence | |
| |*Employee Disability |
| |Please attach job description |
| |*Pregnancy Disability |
| |Expected Due Date: (Attach FMLA Letter that was issued to employee) |
| |Health care for spouse, domestic partner, child, or parent | |
| |Adoption/Foster Care | |
| |Birth and care of newborn child | |
| |*Work Incurred Injury - Workers’ Comp |Workers’ Comp Claim Filed: |
| |Last Day of Extended Sick Leave (80% ESL): |Approved Pending |
| | | |
| | |Option 1 Option 2 Option 3 |
| |Please attach job description | |
| |Military | |
| |Temporary Layoff | |
| |Furlough | |
| |Personal | |
|EMPLOYEE NAME: |
| |
|*Briefly describe present job duties (e.g., routine office, laborer, custodial, patient care, etc.) |
| |
|PART 3 – Leave of Absence and Time Certification |
|(TO BE COMPLETED BY DEPARTMENT REP) |
| |Dates |
| |(Month/Day/Year) |
|Last Day Actively Worked: | |
|Number of Hours Worked on Last Day Worked: | |
|Last Day on Pay Status Using Sick Leave: | |
|Last Day on Pay Status Using Vacation Leave: | |
|Last Day on Pay Status Using Comp Time: | |
|Leave of Absence Without Pay Begin Date: | |
|Anticipated Return to Work/Pay Status Date: | |
|(This includes return to pay status by use of vacation leave) | |
|Separation Date, if applicable | |
|COMMENTS: |
|PART 4 – FMLA Information |
|(TO BE COMPLETED BY DEPARTMENT REP) |
|Is any period of this leave of absence approved as FMLA? Yes No |
|If yes, provide period designated as FMLA: |Leave Begin: Leave End: |
|Period of FMLA with Pay: |Leave Begin: Leave End: |
|(This includes use of vacation and sick leave) | |
|Period of FMLA without Pay: |Leave Begin: Leave End: |
|PART 5 – University Contribution Indicator (UCI) |
|(TO BE COMPLETED BY DEPARTMENT REP) |
|This section must be completed only for FMLA, Disability, Furlough and Temporary Layoff leaves of absence in order for the University Contributions toward medical,|
|dental and vision, if applicable, to be applied in accordance with policy and charged to the appropriate department |
|Benefit Account(s) to be Charged While Employee is on Leave Without Pay |
|Up to three (3) benefit accounts may be charged while an employee is on leave of absence. Charges will be prorated based on percent entered in last column. If |
|only one account is to be charged, only complete the top line and enter 100%. |
|Location Code |Account |CC |Fund |Project |Percent |
|4 | | | | | |
|4 | | | | | |
|4 | | | | | |
EMPLOYEE NAME:
|PART 6 – EDB Certification & Authorization |
|(TO BE COMPLETED BY DEPARTMENT REP) |
|I certify that the leave of absence has been approved and that the leave periods are properly recorded in EDB as appropriate. Date Leave of Absence entered in |
|EDB: |
|EDB Preparer: |Department: HR |
|Phone extension: |Department Fax: Mail Code: |
|Date: | |
|Leave of Absence Approved by: |Phone extension: |
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