1. Supervisor fills out this form approximately 5 days prior to the employee's first day on leave (or as soon as possible for unscheduled events).
   By clicking the "Submit" button below, this form is sent as an email to the HR Records, Benefits, and Payroll units (and also Workers Compensation for workplace injuries). Forms are no longer sent to Labor Relations.

2. Supervisor clicks the "Print" button after submitting the form. A copy must be provided to the employee and a copy must be kept in a department file (a confidential file separate from the department personnel file).

3. You must continue to submit timesheets to Payroll and track amount of time the employee is off work on leave(s).

4. If information changes, such as the start or end dates, for the employee's leave of absence, the supervisor must submit a "Revised Request" form to provide updated information. The updated information is necessary to correct data in eHR/PPS computer systems. Failure to provide updated information may negatively affect an employee's pay and benefits.

5. For medically related leaves, employees must submit to their supervisor a Medical Certification form completed by a health care provider when initially requesting a leave of absence. Employees must submit new medical certification to keep medical documentation current and at least once annually for chronic conditions.

6. To protect employee privacy, Medical Certification forms shall remain at the department in a file separate from departmental personnel files. (Do not send medical certification forms to Payroll or Human Resources)
   Exception: For Residents/Fellows, send medical certification form to Resident/Fellow Program, Human Resources.

7. For workplace injuries, submit forms to the Workers' Compensation Unit in addition to this LOA form. Call Workers' Compensation Unit with questions at 734-6180.

8. For military leave, fax orders and complete paperwork to Payroll (Fax: 734-9167 / Tel: 734-9150) and HR Records (Fax: 734-1754 / Tel: 734-2705).

9. Questions related to Disability and Benefits should be directed to the Benefits Office at 734-8099 or 734-5338.

10. Leaves of Absence may not extend beyond six (6) months without approval by the Executive Director of Human Resources, except as provided for in applicable labor contract provisions.

11. Employees taking a leave of absence due to their own serious health condition, other medical reason or workers' compensation leave must submit a Return to Work Clearance Form prior to returning to work.
    Return to Work Clearance Form is available at: http://www.ucdmc.ucdavis.edu/hr/hrdepts/labor_relations/Forms/RTWForm.pdf

Information is available online at: http://www.ucdmc.ucdavis.edu/hr/hrdepts/labor_relations/fmla_kit.html

1. Has this employee worked for U.C. for at least one year and worked more than 1,250 hours in the past 12-month period? *   Yes   No


2. An employee may not take more than 12 weeks of FMLA or CFRA per calendar year. Has this employee already taken 12 week of FMLA/CFRA during the current calendar year? *   Yes   No


3. For medically related leaves, an employee must submit a current Medical Certification Form (or Medical Status Form for Workers' Compensation) to his/her supervisor. Has this employee submitted a Medical Certification Form (or Medical Status Form for Workers' Compensation) to you?   Yes   No


4. Is this employee a Medical Resident, Medical Intern or Fellow? *   Yes   No


5. Is this leave of absence related to a workplace injury / workers' compensation claim? *   Yes   No

For departments on ecotime: https://hbsecotime.ucdmc.ucdavis.edu/ecotimesso/

For departments not on Kronos: http://tornado/psp/hrprod/?cmd=login