Form DFEH-100-21 "Family Care and Medical Leave (Cfra Leave) and Pregnancy Disability Leave" - California

What Is Form DFEH-100-21?

This is a legal form that was released by the California Department of Fair Employment & Housing - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the California Department of Fair Employment & Housing;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DFEH-100-21 by clicking the link below or browse more documents and templates provided by the California Department of Fair Employment & Housing.

ADVERTISEMENT
ADVERTISEMENT

Download Form DFEH-100-21 "Family Care and Medical Leave (Cfra Leave) and Pregnancy Disability Leave" - California

Download PDF

Fill PDF online

Rate (4.4 / 5) 49 votes
FAMILY CARE
&
MEDICAL LEAVE
THE DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING
PREGNANCY
THE MISSION OF THE DEPARTMENT OF FAIR EMPLOYMENT
&
AND HOUSING IS TO PROTECT THE PEOPLE OF CALIFORNIA
FROM UNLAWFUL DISCRIMINATION IN EMPLOYMENT,
DISABILITY
HOUSING, BUSINESS ESTABLISHMENTS, AND STATE-FUNDED
PROGRAMS AND ACTIVITIES, AND FROM HATE VIOLENCE
AND HUMAN TRAFFICKING.
LEAVE
Under California law, you may have the right to
We may require certification from your health care provider
before allowing you a leave for pregnancy disability or for
take job-protected leave to care for your own
your own serious health condition. We also may require
serious health condition or a family member
certification from the health care provider of your child,
with a serious health condition, or to bond with
parent or spouse, who has a serious health condition,
a new child (via birth, adoption, or foster care).
before allowing you a leave to take care of that family
member. When medically necessary, leave may be taken
California law also requires employers to provide
on an intermittent or reduced work schedule.
job-protected leave and accommodations to
employees who are disabled by pregnancy,
If you are taking a leave for the birth, adoption, or foster care
placement of a child, the basic minimum duration of the
childbirth, or a related medical condition.
leave is two weeks, and you must conclude the leave within
one year of the birth or placement for adoption or foster care.
Under the California Family Rights Act of 1993 (CFRA), if
you
Taking a family care or pregnancy disability leave may impact
certain of your benefits and your seniority date. If you want
more information regarding your eligibility for a leave and/or
the impact of the leave on your seniority and benefits,
please contact your employer.
If you have been subjected to discrimination, harassment,
or retaliation at work, or have been improperly denied PDL
or CFRA leave, file a complaint with DFEH.
Even if you are not eligible for CFRA leave, if you are
TO FILE A COMPLAINT
disabled by pregnancy, childbirth or a related medical
condition, you are entitled to take a pregnancy disability
Department of Fair Employment and Housing
leave of up to four months, depending on your period(s)
dfeh.ca.gov
of actual disability. If you are CFRA-eligible, you have
Toll Free: 800.884.1684
TTY: 800.700.2320
certain rights to take BOTH a pregnancy disability leave
and a CFRA leave for reason of the birth of your child. Both
If you have a disability that requires a reasonable
leaves contain a guarantee of reinstatement-for pregnancy
accommodation, DFEH can assist you with your complaint.
disability it is to the same position and for CFRA it is to the
Contact us through any method above or, for individuals who
same or a comparable position-at the end of the leave,
are deaf or hard of hearing or have speech disabilities, through
the California Relay Service (711).
subject to any defense allowed under the law.
If possible, you must provide at least 30 days’ advance notice
for foreseeable events (such as the expected birth
of a child or a planned medical treatment for yourself or of
a family member). For events that are unforeseeable, we
need you to notify us, at least verbally, as soon as you learn
of the need for the leave. Failure to comply with these
notice rules is grounds for, and may result in, deferral of
the requested leave until you comply with this notice policy.
DFEH-100-21ENG / January 2021
FAMILY CARE
&
MEDICAL LEAVE
THE DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING
PREGNANCY
THE MISSION OF THE DEPARTMENT OF FAIR EMPLOYMENT
&
AND HOUSING IS TO PROTECT THE PEOPLE OF CALIFORNIA
FROM UNLAWFUL DISCRIMINATION IN EMPLOYMENT,
DISABILITY
HOUSING, BUSINESS ESTABLISHMENTS, AND STATE-FUNDED
PROGRAMS AND ACTIVITIES, AND FROM HATE VIOLENCE
AND HUMAN TRAFFICKING.
LEAVE
Under California law, you may have the right to
We may require certification from your health care provider
before allowing you a leave for pregnancy disability or for
take job-protected leave to care for your own
your own serious health condition. We also may require
serious health condition or a family member
certification from the health care provider of your child,
with a serious health condition, or to bond with
parent or spouse, who has a serious health condition,
a new child (via birth, adoption, or foster care).
before allowing you a leave to take care of that family
member. When medically necessary, leave may be taken
California law also requires employers to provide
on an intermittent or reduced work schedule.
job-protected leave and accommodations to
employees who are disabled by pregnancy,
If you are taking a leave for the birth, adoption, or foster care
placement of a child, the basic minimum duration of the
childbirth, or a related medical condition.
leave is two weeks, and you must conclude the leave within
one year of the birth or placement for adoption or foster care.
Under the California Family Rights Act of 1993 (CFRA), if
you
Taking a family care or pregnancy disability leave may impact
certain of your benefits and your seniority date. If you want
more information regarding your eligibility for a leave and/or
the impact of the leave on your seniority and benefits,
please contact your employer.
If you have been subjected to discrimination, harassment,
or retaliation at work, or have been improperly denied PDL
or CFRA leave, file a complaint with DFEH.
Even if you are not eligible for CFRA leave, if you are
TO FILE A COMPLAINT
disabled by pregnancy, childbirth or a related medical
condition, you are entitled to take a pregnancy disability
Department of Fair Employment and Housing
leave of up to four months, depending on your period(s)
dfeh.ca.gov
of actual disability. If you are CFRA-eligible, you have
Toll Free: 800.884.1684
TTY: 800.700.2320
certain rights to take BOTH a pregnancy disability leave
and a CFRA leave for reason of the birth of your child. Both
If you have a disability that requires a reasonable
leaves contain a guarantee of reinstatement-for pregnancy
accommodation, DFEH can assist you with your complaint.
disability it is to the same position and for CFRA it is to the
Contact us through any method above or, for individuals who
same or a comparable position-at the end of the leave,
are deaf or hard of hearing or have speech disabilities, through
the California Relay Service (711).
subject to any defense allowed under the law.
If possible, you must provide at least 30 days’ advance notice
for foreseeable events (such as the expected birth
of a child or a planned medical treatment for yourself or of
a family member). For events that are unforeseeable, we
need you to notify us, at least verbally, as soon as you learn
of the need for the leave. Failure to comply with these
notice rules is grounds for, and may result in, deferral of
the requested leave until you comply with this notice policy.
DFEH-100-21ENG / January 2021