This reference page is intended to help departments coordinate paperwork while an employee is on an unpaid or paid leave of absence. This does not replace the regulatory documents that govern the process.
Coordination of paperwork when an employee in your department is off work more than a few days is very important. Department Personnel Representatives work to maintain compliance with federal/state law and to provide the appropriate information to the employee. This information may explain protections available under the law and/or the employee's benefits options while on a leave of absence. If you have any questions about appropriate forms not answered on this reference sheet, please call your designated Personnel Technician in the Personnel Services Department.
When an employee requests a paid or unpaid leave, the following paperwork must be completed or provided:
FMLA/CFRA /PDL Paperwork (Assuming Eligibility)
Please click here to read a brief summary of FMLA changes that took effect on January 16, 2009.
Departmental Leave of Absence Packet (with 2019 Rates) - Packet contains the following notices:
- General Notice (Notice I) - Employee Rights and Responsibilities Under the Family and Medical Leave Act (FMLA) and/or the California Family Rights Act (CFRA) and/or Pregnancy Disability Leave (PDL). This notice summarizes eligibility, rights and responsibilities for the employee. This should be provided to the employee within five days of either a request for leave or after learning that a leave may be FMLA/CFRA and/or PDL qualifying.
- Eligibility Notice (Notice II) - Notice of Eligibility and Rights & Responsibilities - FMLA/CFRA/PDL. This form documents the employee’s basic eligibility for FMLA/CFRA and communicates whether additional information is required to qualify.
- Designation Notice (Notice III) - Designating Leave as FMLA/CFRA, More Info Needed or Not Approved. This form documents that the employee qualifies for FMLA and/or CFRA.
As explained in the FMLA Update Summary document, there are also two types of protected leave for an employee with a family member in the military (Military Caregiver Leave and Qualifying Exigency Leave). Click here for new information related to Family Military Leaves (updated March 2013).
To qualify for the new types of leave, the following certifications must be completed:
- Certification for Serious Injury or Illness of Covered Service member for Military Family Leave
- Certification for Serious Injury or Illness of Veteran for Military Family Leave
- Certification Of Qualifying Exigency for Military Family Leave
General Leave of Absence Paperwork
Departmental Leave of Absence Packet (With 2019 Rates) - Packet contains the following forms:
- Leave of Absence Request Form (Form A) - This form should be completed by the employee even if they are on paid status during their leave (using Annual Leave). It indicates the duration/reason for the leave and allows the employee to elect health insurance options should they run out of Annual Leave (paid leave). If the leave is paid, the department will maintain this form in the employees file. If the leave is unpaid or in the event the leave becomes unpaid, the department must complete the department section of the form and submit the form along with the JCI to Employee Benefits.
- Leave of Absence Request Form Confirmation (Form C) - This form must be signed by the employee and includes the cost of health insurance while they are on leave. The cost of each health insurance option is on page 6 of the LOA packet. It is recommended that the employee find their plan and cost and fill in the amount. This must be completed or the form is incomplete. If the employee does not know who their health provider is, please have them contact Employee Benefits.
- FMLA Insurance Continuation Election Form – Parts 1 & 2 (Form D) - This form is used by the County’s Third Party Administrator (ASI) to bill the employee for their health insurance elections and must be completed to maintain coverage on an unpaid LOA.
COBRA Paperwork: If the employee is on Non-FMLA/CFRA leave, a COBRA notice will be issued to the employee and their eligible dependents by the County's COBRA administrator, Administrative Solutions, Inc. (ASI) through the mail.
- 4850 Leave (Safety Employees): This pertains to the Sheriff’s Office, Probation Department and District Attorney's Office. FMLA does not run concurrent with 4850 pay. Once the 4850 pay is exhausted and all paid time-off has been taken, the department must submit a JCI to Employee Benefits placing the employee on a Leave of Absence (FMLA or LOA). ASI will then issue the employee and their eligible dependents a COBRA notice through the mail.
Other Information That Should Be Provided
- Annual Leave Donation Program: Department should inform employees of the County’s Annual Leave Donations Program. If the employee is interested in requesting donations, the department should provide the employee with a copy of the procedures or direct them to the Employee Benefits website to review information on the program.
- State Disability Insurance: For employees that are eligible to integrate with State Disability/PDL , the departments should provide the SDI/ PFL Integration packet to employees. The eligible bargaining units for this benefit are listed on the SDI/PFL integration packed.
ADA/FEHA Interactive Process Guide and Forms
- ADA/FEHA Accommodation Form
- This form is to be completed by the employee's health care provider. It's purpose is to identify an employee's specific limitations and whether a reasonable accommodation can be made.
- Please note that this form must be accompanied by the employee's Essential Functions Inventory Form as a reference for the health care provider.
When an employee exhausts Annual Leave, it is essential that a JCI form is submitted placing the employee on a leave of absence.
The following paperwork must be completed/included with the PAN/JCI paperwork:
- Departmental Leave of Absence Checklist
- Leave of Absence Request Form (Form A)
- Leave of Absence Request Form Confirmation (Form C)
- FMLA Insurance Continuation Election Form – Parts 1 & 2 (Form D) – if the employee has elected to continue health insurance on Form A
If the leave is FMLA/CFRA qualifying, please also include:
- Eligibility Notice (Notice II)
- Designation Notice (Notice III)
In the Event Paperwork Not Complete or Returned
If an employee is going on an unpaid leave of absence but has not completed the “Leave of Absence Request Form – Form A”, please submit the PAN/JCI form placing the employee on an unpaid LOA. In the comments section, please indicate “no leave paperwork received”. If the paperwork is received at a later date, please submit another PAN/JCI with the appropriate paperwork. Please note that in the absence of the paperwork above, all benefits will terminate.
It is still the responsibility of the employee to submit the appropriate leave of absence paperwork in accordance with Personnel Rules. Depending on the circumstances, lack of paperwork may require the department to consider the employee “absent without leave” (AWOL) and may require disciplinary action (please contact County Counsel for more information). Departments should document their efforts in attempting to contact the employee. If paperwork is not returned and approved leave has expired, it is recommended that you send a letter to the employee informing them they are considered absent without approval leave.