Departments Reference Page - Leave of Absence

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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 2020 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:

General Leave of Absence Paperwork

Departmental Leave of Absence Packet (With 2020 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.


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

JCI Paperwork

When an employee exhausts Annual Leave, it is essential that a JCI form is submitted placing the employee on a leave of absence.


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