Leave-of-Absence-F272-01.1816e.doc



COUNTY OF ORANGE LEAVE OF ABSENCE FORM

|SECTION I |

|EMPLOYEE NAME |     |EMPLOYEE ID |      |

|AGENCY/DEPARTMENT |      |CLASSIFICATION |      |

|Requested dates of absence (first day off work) |      |Return Date: |      |

|Initial Request or Extension Request |Apply Annual Leave/Sick time before or after Leave |

|TYPE OF LEAVE |

| MEDICAL - Attach statement of attending physician (including anticipated | PARENTHOOD LEAVE (This may include CFRA) – Attach documentation of expected |

|length of disability) |birth or adoption |

|PERSONAL MEDICAL |MILITARY - Attach Military Orders |

|FAMILY MEMBER MEDICAL – |OTHER - Explain (Personal, educational, etc.) |

|Specify Relationship ____________________________ | |

| | |

|PREGNANCY (PDL) - Attach statement of attending physician (including | |

|anticipated length of disability) | |

|EXPLANATION: |      |

| |

|IT IS YOUR RESPONSIBILITY TO NOTIFY YOUR SUPERVISOR OF ANY CHANGES TO YOUR LEAVE |

|SIGNATURE OF EMPLOYEE |__________________________________________CONTACT PHONE NUMBER ___________________________ |

| |

|SECTION II - Supervisor's Review |

| Recommend Approval: requested leave is non-discretionary pursuant to | Recommend Approval: requested leave is discretionary pursuant to Memorandum of |

|State/Federal law, Memorandum of Understanding or Personnel and Safety Resolution|Understanding or Personnel and Salary Resolution provisions (complete and attach |

|provisions |worksheet for Discretionary Leaves) |

| Recommend Denial (Reason): |      |

|SIGNATURE | |DATE |      |

| |

|SECTION III - Program/Division Management |

| Recommend Approval Modify as follows: |      |

| Recommend Denial (Reason): |      |

|SIGNATURE | |DATE |      |

|SECTION IV – Agency/Department Head Authorization |

| Recommend Approval Modify as follows: |      |

| Recommend Denial (Reason): |      |

|SIGNATURE | |DATE |      |

| |

|SECTION V – Agency/Department Human Resources Manager/Designee |

| Approved Denied |

|SIGNATURE | |DATE |      |

| |

|AGENCY/DEPARTMENT HUMAN RESOURCES USE ONLY |

|LAST DAY WORKED |      |FIRST DAY OFF PAYROLL |      |

|DEPARTMENTAL LEAVE |      |OFFICIAL LEAVE |      |

|CATASTROPHIC LEAVE |      |FAMILY & MEDICAL LEAVE HOURS BALANCE AVAILABLE |      |

|EXTENSION |      |PREGNANCY DISABILITY LEAVE BALANCE AVAILABLE |       |

|CFRA (BABY BONDING) LEAVE | |MILITARY LEAVE |      |

|COMMENTS |

| |

Distribution: HR Medical File; Employee; DEPT. File Revised: 12/9/11

COUNTY OF ORANGE

LEAVE OF ABSENCE GUIDELINES

NOTICE TO EMPLOYEE WHOSE LEAVE OF ABSENCE HAS BEEN APPROVED

A. If you wish your medical insurance coverage to continue for you and your dependents and have not made the necessary arrangements, you should contact the Benefits Center immediately at (866)325-2345. Failure to continue medical coverage on your dependents can result in them having to provide evidence of insurability before it can be reinstated.

B. You must give (2) weeks notice prior to the date you plan to return to work, except if you are returning from Family Leave. If you are returning from FMLV, you must give the maximum notice allowable under applicable law. If you do not give adequate prior notice, your return to work may be delayed.

C. If you wish to ask for an extension of your official leave of absence, the request must be made in the same manner as the original request and submitted at least two (2) weeks prior to the return date on the original leave of absence request.

D. Failure to return to work at the expiration of a leave of absence, or being absent without authorized leave for a period of three (3) consecutive working days, may be considered an automatic resignation.

E. The County of Orange may discontinue health insurance benefits if the employee fails to pay his/her portion of the

benefits or return to work.

GUIDELINES FOR APPLYING FOR:

FAMILY & MEDICAL LEAVE/CALIFORNIA FAMILY RIGHTS ACT (FMLA/CFRA)

If an employee has been employed by the County for 12 months (non-consecutive) and has worked at least 1250 hours during the 12 months immediately prior to the requested leave, 12 weeks per calendar year (up to 480 hours for full-time employees) of Family and Medical Leave/California Family Right Act must be granted in the following situations (refer to applicable MOU or PSR for additional leave provisions):

a. An employee's serious health condition.

b. Care for the employee's child after birth or placement of a child for adoption or foster care.

c. Employee's presence is needed to attend to a serious health condition of the employee's child, spouse, parent, or child of an employee standing in "loco parentis" who is either under eighteen (18) years old or an adult dependent child incapable of self-care because of mental or physical disability.

The County shall determine if a request for FMLA/CFRA is valid within the parameters of applicable law and

request supporting documentation as needed.

When a request for FMLA/CFRA is approved, the Agency/Department should consult the applicable MOU to determine if sick leave, annual leave, compensatory and/or vacation time can be applied. If the need for FMLA/CFRA can be anticipated, the Agency/Department may require the employee to provide notice of pending leave before the leave can be taken and/or to schedule care and treatment appointments to minimize disruption to the Agency/Department operations, as practicable. (Refer to applicable MOU or PSR).

PREGNANCY DISABILITY LEAVE (PDL)

If a female employee plans to go out on pregnancy disability leave, she must provide her supervisor with medical certification. The certification must show date of disability and time needed off work. The employee should provide 30 days of notice to her supervisor or as much notice in advance as practicable.

Pregnancy Disability Leave (PDL) must be granted when there is a qualifying event concerning pregnancy, childbirth, and related conditions. These events include, but are not limited to, bedrest ordered by your doctor; childbirth and recovery from childbirth; prenatal visits and care; and severe morning sickness.

Women who qualify for Pregnancy Disability Leave are eligible for up to 4 months of unpaid leave in a calendar year. The County will continue to pay its’ share of health insurance premiums, and the employee would still be obligated to pay her share.

CALIFORNIA FAMILY RIGHTS ACT (CFRA or BONDING LEAVE)

California Family Rights Act (CFRA) provides for up to twelve weeks off to care for a newborn child, newly adopted child, or a child newly placed in foster care (often referred to as “baby bonding”). CFRA leave is provided to either parent for birth, adoption, or foster placement of a child. However, spouses who work for the same employer may only take 12 weeks of combined leave when a child’s birth, adoption or foster care is involved.

An employee who is disabled due to pregnancy, childbirth, or related medical conditions is entitled to take Pregnancy Disability Leave (PDL) for the period up to four (4) months in addition to the 12 weeks of leave provided by the California Family Rights Act (CFRA).

Bonding leave may be taken consecutively or intermittently but must be taken within one year of the qualifying event. The employee must inform the supervisor of the decision to take bonding leave as soon as possible and tell the supervisor the amount of time s/he is requesting to be off work.

NOTICE TO EMPLOYEES WHOSE LEAVE HAS NOT BEEN APPROVED

If your initial request for leave of absence has not been approved, you or your dependent may, within fifteen (15) calendar days of this notice of denial, file a request with the Agency/Department Human Resources that the official leave of absence request be reviewed by the Human Resources Director. (Refer to applicable MOU or PSR).

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