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Leave of Absence - Family, Medical and Parental Leave Forms

  • Basic Poster and Notice Requirements under the Family, Medical and Pregnancy Leave Laws
    Review this chart to determine your responsibilities under family, medical and pregnancy leave laws.
  • Basic Poster and Notice Requirements under the Family, Medical and Pregnancy Leave Laws - Spanish
    Review this chart to determine your responsibilities under family/medical and pregnancy leave laws. ​​​
  • Benefits During Leaves of Absence
    This chart describes leaves of absence, whether they are legally required, if state mandated wage replacement is available, whether health benefits must be continued during the leave, whether use of sick, vacation or PTO can be required and whether sick, vacation or PTO accrue during the leave.
  • California Family Rights Act Brochure
    This brochure outlines an employee's right for leave under the California Family Rights Act (CFRA). You may choose to give this brochure to each employee eligible for CFRA and/or who requests leave that qualifies as CFRA, but there is no requirement that you do so.​​
  • California Family Rights Act Brochure - Spanish
    This brochure outlines an employee’s right for leave under the California Family Rights Act (CFRA).​ You may choose to give this brochure to each employee eligible for CFRA and/or who requests leave that qualifies as CFRA, but there is no requirement that you do so.​
  • Certification for Serious Injury or Illness of a Current Servicemember - for Military Family Leave - Family and Medical Leave Act
    Use this form when an employee requests leave to care for a close family member or next of kin who has a serious injury or illness relating to current military service. California employers - note especially the stated limitations relating to medical information as this information is confidential and protected in California.​ 
  • Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave - Family and Medical Leave Act
    Personalize
    Use this form when an employee requests leave to care for a close family member or next of kin who is a veteran and who has a serious injury or illness relating to his/her military service. California employers - note especially the stated limitations relating to medical information as this information is confidential and protected in California.​
  • Certification of Health Care Provider - Employees or Family Members Serious Health Condition
    Updated | Personalize
    Have the employee's health care provider complete this medical certification as needed. This form is used for employee's taking leave under the Family and Medical Leave Act (FMLA) and California Family Rights Act (CFRA) for their own serious health condition or that of a family member.​​​​
  • Certification of Health Care Provider - Employees or Family Members Serious Health Condition - Spanish
    Personalize
    Have the employee's health care provider complete this medical certification as needed. This form is used for employee's taking leave under the Family Medical Leave Act (FMLA) and California Family Rights Act (CFRA) for their own serious health condition or that of a family member.​​​
  • Certification of Health Care Provider for Employee Return to Work
    Personalize
    An employee may use this notice to have his/her health care provider certify that he/she may return to work.
  • Certification of Health Care Provider for Pregnancy Disability Leave, Transfer And/Or Reasonable Accommodation
    Personalize
    Have the employee's health care provider complete this medical certification as needed. This form is used for employee's seeking reasonable accommodation, transfer or Pregnancy Disability Leave for pregnancy, childbirth or a related medical condition.​​
  • Certification of Qualifying Exigency for Military Family Leave - FMLA only
    Use this form when an employee requests leave due to a qualifying exigency relating to a family member's military service. California employers - note especially the stated limitations relating to medical information as this information is confidential and protected in California.
  • Family Care and Medical Leave and Pregnancy Disability Leave Notice - 20 or More Employees
    Free
    This notice must be posted and must also be given to an employee who is seeking pregnancy disability leave or reasonable accommodation/transfer for pregnancy, childbirth or related medical condition and/or who is seeking family care or medical leave. This notice applies to California employers with 20 or more employees (subject to the NPLA, CFRA or FMLA). You must post this notice in a place commonly used by employees, such as a break room. Employers are also encouraged to give this notice at time of hire to each new employee. This notice is also part of the California and Federal Employment Notices Poster available at the CalChamber Store.​​
  • Family Care and Medical Leave and Pregnancy Disability Leave Notice - 20 or More Employees - Spanish
    Free
    This notice must be posted and must also be given to an employee who is seeking pregnancy disability leave or reasonable accommodation/transfer for pregnancy, childbirth or related medical condition and/or who is seeking family care or medical leave. This notice applies to California employers with 20 or more employees (subject to the NPLA, CFRA or FMLA). You must post this notice in a place commonly used by employees, such as a break room. Employers are also encouraged to give this notice at time of hire to each new employee. This notice is also part of the California and Federal Employment Notices Poster available at the CalChamber Store.
  • Federal Family and Medical Leave Act Poster
    This poster satisfies the required federal posting notice regarding the availability of family and medical leave.

    Employers should give a copy of this FMLA notice at the time of hire if they do not publish an employee handbook​. Best practice is to provide the notice at time of hire regardless of whether you also include the notice in your employee handbook.​​​​​
  • Federal Family and Medical Leave Act Poster - Spanish
    This poster satisfies the required federal posting notice regarding the availability family and medical leave.

    Employers should give a copy of the FMLA notice at the time of hire if they do not publish an employee handbook. Best practice is to provide the notice at time of hire regardless of whether you also include the notice in your employee handbook.​​​​
  • FMLA - Family Member Leave for a Qualifying Exigency
    This chart describes the types of events that give an eligible employee a reason for leave because of a qualifying exigency under the FMLA arising because the spouse, son, or child of the employee is on covered active duty or call to active duty.​ 
  • FMLA - Family Member Leave for a Qualifying Exigency - Spanish
    This chart describes the types of events that give an eligible employee a reason for leave because of a qualifying exigency under the FMLA arising because the spouse, son, or child of the employee is on covered active duty or call to active duty.​ ​
  • FMLA - Notice of Eligibility and Rights and Responsibilities
    Updated | Personalize
    Use this form to notify employees taking a family medical leave only regarding their eligibility for leave and any associated righ​ts and responsibilities.​ ​​
  • FMLA - Notice of Eligibility and Rights and Responsibilities - Spanish
    Personalize
    Use this form to notify employees taking a family medical only leave regarding their eligibility for leave and any associated rights and responsibilities. ​​
  • FMLA CFRA Designation Notice
    Updated | Personalize

    Use this form to designate leave as FMLA/CFRA, to provide conditional approval of the request for leave if more information is necessary or to deny the request.

  • FMLA CFRA Designation Notice - Spanish
    Personalize

    Use this form to designate leave as FMLA/CFRA, to provide conditional approval of the request for leave if more information is necessary, or to deny the request.​​​

  • FMLA CFRA Documentation Checklist for Employer Use Only
    Use this checklist to assist you in complying with all regulations regarding family medical leave and CFRA leave. ​​​
  • FMLA PDL Designation Notice
    Updated | Personalize
    Use this form to notify an employee if their leave for PDL/FMLA is approved, conditionally approved or denied. 
  • FMLA PDL Designation Notice - Spanish
    Personalize
    Use this form to notify an employee if their leave for PDL/FMLA is approved, conditionally approved or denied.
  • FMLA Sample Policy — 50 or More Employees
    Use this policy to satisfy the requirements regarding family and medical leave.​
  • FMLA Sample Policy — 50 or More Employees — Spanish
    Use this policy to satisfy the requirements regarding family and medical leave.​​​​​
  • Lactation Accommodation Policy
    Personalize
    Provide this policy to employees which states your company recognizes lactating employees' rights to request lactation accommodation. A written policy is mandatory for all California employers, regardless of size. In addition to including this policy in an employee handbook or set of policies, you must provide this policy to employees upon hiring and when an employee asks about or requests parental leave. Download and read the Instructions prior to using this policy.
  • Lactation Accommodation Policy — Instructions
    Download and read these instructions prior to using the Lactation Accommodation Policy.
  • Leave Interaction
    Updated
    When an employee considers a leave, use this form to determine the relationships among the various state-mandated leaves of absence and benefits during the time off. Employees also benefit from this information.
  • New Parent Leave Act (NPLA) Acknowledgment
    Personalize
    Give this notice to an employee who is seeking time off to bond with a new child or a child placed for adoption or foster care under California’s New Parent Leave Act (NPLA), which applies to employers with 20 or more employees. The NPLA requires that employers provide employees with a guarantee of reinstatement before an employee begins his/her Parental Leave. This form will provide employees with notice of their reinstatement rights and other important information.

    If the employee is covered by FMLA/CFRA, use the FMLA/CFRA Designation Notice and FMLA — Notice of Eligibility and Rights and Responsibilities instead.
  • New Parent Leave Act (NPLA) Acknowledgment - Spanish
    Personalize
    Give this notice to an employee who is seeking time off to bond with a new child or a child placed for adoption or foster care under California’s New Parent Leave Act (NPLA), which applies to employers with 20 or more employees. The NPLA requires that employers provide employees with a guarantee of reinstatement before an employee begins his/her Parental Leave. This form will provide employees with notice of their reinstatement rights and other important information.

    If the employee is covered by FMLA/CFRA, use the FMLA/CFRA Designation Notice — Spanish and FMLA — Notice of Eligibility and Rights and Responsibilities — Spanish instead.
  • New Parent Leave Act (NPLA) Leave Checklist – 20 or More Employees
    If your company has 20 or more full- or part-time employees, your employees may be eligible for up to 12 weeks of New Parent Leave Act (NPLA) leave to bond with a newborn or child placed with the employee for adoption or foster care. This is protected time off that comes with a guarantee of reinstatement at the end of the leave and continuation of health benefits during the leave. Use this checklist for each employee who requests NPLA leave to help you manage the leave process.
  • PDL FMLA CFRA Documentation Checklist - For Employer Use Only
    Use this checklist to assist you in complying with regulations regarding family medical leave, CFRA leave and pregnancy disability leave.​​
  • Request for Leave of Absence - FMLA CFRA PDL
    Provide this form if you're an employer covered by the federal Family and Medical Leave Act (FMLA) or the California Family Rights Act (CFRA) and either an employee has requested a leave of absence or you recognize the need.
  • Request for Leave of Absence - FMLA CFRA PDL - Spanish
    Provide this form if you're an employer covered by the federal Family and Medical Leave Act (FMLA) or the California Family Rights Act (CFRA) and either an employee has requested a leave of absence or you recognize the need.
  • Summary of Family Medical, Pregnancy Disability and Parental Leave Laws
    This form summarizes employer obligations as provided in federal and state family and medical leave laws ​(FMLA/CFRA), the California New Parent Leave Act and the California Pregnancy Disability Leave law. It also shows the relationship between these laws and benefits available to employees while taking these leaves. ​​