"Request for Leave and Leave Protections" - City and County of San Francisco, California

Request for Leave and Leave Protections is a legal document that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco.

Form Details:

  • Released on December 1, 2020;
  • The latest edition currently provided by the Department of Human Resources - City and County of San Francisco, California;
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For All Continuous and
City and County of San Francisco
Intermittent Absences of
More than 5 Days, Including
Request for Leave and Leave Protections
FMLA/CFRA
New Request
Request for Extension
1
Name: ___________________________ DSW#: ______________ Class/Title: __________________________________
Address: ________________________________________ City: _______________________ State: ____ Zip: _________
Contact No.: _____________________ Home Email: ______________________________ Dept.: __________________
Supervisor: ____________________________
Employment Status:
Permanent
Probationary
Exempt
Type of Leave and/or Job Protection Requested
(Check All That Apply):
Temporary
Provisional
1. LEAVE REASON
Sick Leave for (check one):
Personal Leave
Attach Medical Certification
My Own Illness or Care
Educational Leave
Pregnancy or Related Condition
To Accept Other City Employment:
TEX
PEX
Child Bonding or Assumption of Child Rearing
Care for Next of Kin Covered Military Service Member
(Birth/Placement Date: __________________)
Military Exigency Related to Deployment
Care for Ill Family Member
Other, Please Specify: _______________________
State Relationship and Type of Care to be Provided:
__________________________________________
2. LEAVE PROTECTIONS
2
__________________________________________
Family Medical Leave Act
California Family Rights Act
(attach separate sheet)
Pregnancy Disability Leave
City Family Care Leave
(Permanent Employees Only)
Kin Care
3. OTHER BENEFITS
I
will
will not receive/apply for SDI, PFL or WC.
Department will supplement other benefits with your accruals unless you elect not to do so.
I DO NOT wish to supplement SDI/PFL/WC with accrued Sick Leave, Vacation, Compensatory Time, or Floating Holiday
4. PAY
SP
VA
CTE
FH
For leave that allows pay options I wish to use or supplement other benefits with:
Use of some accrued leaves are required for unpaid FMLA/CFRA or PDL leaves. Please note that pay options may only be allowed for
certain leave types. Please inquire with your Human Resources Department for questions regarding your pay options.
5. AMOUNT OF LEAVE REQUESTED
Continuous
Intermittent
Reduced Schedule From (dates) ______________________ to ______________________
For Intermittent Leave: How Many Leave Hours Per Day?: _______ How Many Absence Days Per Week? _______
OR
How Many Leave Hours Per Week?: ______ How Many Absence Days Per Month? ______
Proposed Reduced Work Schedule: Days: _______________________________ Work Hours: _______________________
____________________________________________________
______________________________
Employee Signature
Date
SIGNATURE
DATE
RECEIVED
APPROVE
DENY
2
PRINT NAME/TITLE
With/Without
Reason
(Employee’s Supervisor)
(Personnel Officer/Designee)
(Appointing Officer/Designee)
Requests for extension of FMLA/CFRA or PDL leave must be submitted two weeks prior to the end of the currently scheduled FMLA/CFRA or PDL
1
leave when practical. Failure to submit timely requests may delay granting the extension.
2
FOLLOWING VERIFICATION OF ELIGIBILITY AND MEDICAL NECESSITY, CERTAIN LEAVES MUST BE DESIGNATED ON FORM FML 3, EVEN IF NOT REQUESTED. THIS
FORM CANNOT BE USED TO APPROVE OR DENY FMLA, CFRA OR PDL PROTECTIONS. SIGNATURE ACKNOWLEDGES RECEIPT OF FMLA, CFRA OR PDL REQUEST ONLY.
Health Benefits: When you are on an unpaid leave, premiums for health coverage cannot be deducted from your paycheck. To maintain coverage,
3
you must contact SFHSS 30 days of when leave begins to arrange for payment.
sfhss.org/contact-us
RFL (Rev. 12/2020)
For All Continuous and
City and County of San Francisco
Intermittent Absences of
More than 5 Days, Including
Request for Leave and Leave Protections
FMLA/CFRA
New Request
Request for Extension
1
Name: ___________________________ DSW#: ______________ Class/Title: __________________________________
Address: ________________________________________ City: _______________________ State: ____ Zip: _________
Contact No.: _____________________ Home Email: ______________________________ Dept.: __________________
Supervisor: ____________________________
Employment Status:
Permanent
Probationary
Exempt
Type of Leave and/or Job Protection Requested
(Check All That Apply):
Temporary
Provisional
1. LEAVE REASON
Sick Leave for (check one):
Personal Leave
Attach Medical Certification
My Own Illness or Care
Educational Leave
Pregnancy or Related Condition
To Accept Other City Employment:
TEX
PEX
Child Bonding or Assumption of Child Rearing
Care for Next of Kin Covered Military Service Member
(Birth/Placement Date: __________________)
Military Exigency Related to Deployment
Care for Ill Family Member
Other, Please Specify: _______________________
State Relationship and Type of Care to be Provided:
__________________________________________
2. LEAVE PROTECTIONS
2
__________________________________________
Family Medical Leave Act
California Family Rights Act
(attach separate sheet)
Pregnancy Disability Leave
City Family Care Leave
(Permanent Employees Only)
Kin Care
3. OTHER BENEFITS
I
will
will not receive/apply for SDI, PFL or WC.
Department will supplement other benefits with your accruals unless you elect not to do so.
I DO NOT wish to supplement SDI/PFL/WC with accrued Sick Leave, Vacation, Compensatory Time, or Floating Holiday
4. PAY
SP
VA
CTE
FH
For leave that allows pay options I wish to use or supplement other benefits with:
Use of some accrued leaves are required for unpaid FMLA/CFRA or PDL leaves. Please note that pay options may only be allowed for
certain leave types. Please inquire with your Human Resources Department for questions regarding your pay options.
5. AMOUNT OF LEAVE REQUESTED
Continuous
Intermittent
Reduced Schedule From (dates) ______________________ to ______________________
For Intermittent Leave: How Many Leave Hours Per Day?: _______ How Many Absence Days Per Week? _______
OR
How Many Leave Hours Per Week?: ______ How Many Absence Days Per Month? ______
Proposed Reduced Work Schedule: Days: _______________________________ Work Hours: _______________________
____________________________________________________
______________________________
Employee Signature
Date
SIGNATURE
DATE
RECEIVED
APPROVE
DENY
2
PRINT NAME/TITLE
With/Without
Reason
(Employee’s Supervisor)
(Personnel Officer/Designee)
(Appointing Officer/Designee)
Requests for extension of FMLA/CFRA or PDL leave must be submitted two weeks prior to the end of the currently scheduled FMLA/CFRA or PDL
1
leave when practical. Failure to submit timely requests may delay granting the extension.
2
FOLLOWING VERIFICATION OF ELIGIBILITY AND MEDICAL NECESSITY, CERTAIN LEAVES MUST BE DESIGNATED ON FORM FML 3, EVEN IF NOT REQUESTED. THIS
FORM CANNOT BE USED TO APPROVE OR DENY FMLA, CFRA OR PDL PROTECTIONS. SIGNATURE ACKNOWLEDGES RECEIPT OF FMLA, CFRA OR PDL REQUEST ONLY.
Health Benefits: When you are on an unpaid leave, premiums for health coverage cannot be deducted from your paycheck. To maintain coverage,
3
you must contact SFHSS 30 days of when leave begins to arrange for payment.
sfhss.org/contact-us
RFL (Rev. 12/2020)
Leaves of Absence - General Provisions
Leaves of absence are governed by the following general provisions:
1.
Leave requests must be submitted to a department head or designee for approval.
2.
A request for leave in excess of five days must be approved in advance on the appropriate form by the employee’s supervisor, department’s
human resources representative, and the appointing officer/designee.
3.
Employees who do not return to work when they are expected are absent without leave (AWOL) and may be subject to disciplinary action or
automatic resignation.
4.
Disapproval of certain types of leave may be appealed either through the grievance procedure in the respective collective bargaining
agreement or the Civil Service Commission Rules.
5.
Except for personal leave and in cases where the employee has obtained the prior approval of the appointing officer and the human resources
director, an employee may not accept employment outside of the City and County service, other than military service, while on a leave of
absence.
Employees should consult their human resources representatives if they have questions or need more information on any of the leaves or leave
requirements described below.
Sick Leave: Except for leave under Labor code Section 233, sick leave requests for over five days must be certified by a licensed medical doctor,
dentist, podiatrist, licensed clinical psychologist, Christian Science practitioner or licensed doctor of chiropractic medicine. Verification of sick leave
for less than five days may be required on an individual basis. Employees are responsible for notifying their supervisors when they are unable to
report for duty because of illness, and of the approximate date of their return to work. The duration of leave requested by the employee on this
form should be the same as the duration certified as medically necessary by the health care provider. Only the amount of sick leave certified by the
health care provider will be approved.
Family Care Leave: If an employee’s leave to care for a newborn, newly adopted child or sick family member extends beyond the 12-week
FMLA/CFRA leave maximum, or if the employee is not eligible for FMLA/CFRA leave, he or she may seek additional unpaid leave of up to a total of
one year for any of the same reasons. This type of leave is available to permanent employees who have completed at least one year of service and
is at the discretion of the department’s appointing officer.
Family Medical Leave Act and/or California Family Rights Act (FMLA/CFRA): Eligible employees may take up to 12 workweeks of unpaid, job-
protected leave in a 12-month period to care for themselves or family members who are ill, or for child bonding and military exigency. FMLA and
CFRA contain similar provisions and may run concurrently in certain circumstances. However, there are specific situation where the leaves will not
run concurrently, and employees may have separate 12-workweek leave entitlements for a total of up to 24 workweeks of job-protected leave. See
Notice of Eligibility, Rights and Responsibilities -- FML1 for more information on these leave entitlements.
Kin Care: Employees may take up to half of the sick leave they accrue annually to care for themselves, or for a child, parent, or guardian, spouse or
registered domestic partner, grandchild, grandparent, or sibling. Employees have the right to designate sick leave as Kin Care for their own health
conditions or that of a qualifying family member. Sick leave not designated as Kin Care may be included in absenteeism rates as a negative
attendance factor.
Leave for Spouse/Registered Domestic Partner While Qualified Member on Leave From Deployment:
In compliance with the State of California Military and Veterans Code, a qualified employee who is a spouse or registered domestic partner of a
qualified member of the Armed Forces, National Guard, or reserves shall be allowed to take up to 10 days of unpaid leave during a period of leave
from deployment of the qualified member.
Jury Duty Leave: Employees must notify their supervisor when a jury summons is received. Any employee who is called to jury duty for a municipal,
state or federal court during the employee’s working hours is allowed his or her regular compensation less the amount of jury fees paid while
serving as a juror. An employee called as a witness in a non-work related matter may be granted leave without pay unless vacation leave or
compensatory time is granted.
Educational Leave: Educational leave is unpaid and is generally available to permanent employees only. An employee may be granted leave not to
exceed one year for the purpose of securing additional education in a field related to his or her position.
Religious Leave: Employees may be granted religious leave when personal religious beliefs require the abstention from work during certain periods
of the work day or work week. Religious leave is without pay unless a request to utilize accumulated compensatory time off, vacation time, or
floating holidays is approved.
Leave to accept other City and County employment. Leave to accept a temporary or exempt appointment in the City is available at the discretion
of the department head for permanent civil service employees only.
Personal Leave: Permanent employees may request unpaid personal leave for up to 12 months within any two year period. The department head
has discretion to grant or deny requests for personal leave. With certain exceptions, temporary or provisional employees may request personal
leave for a maximum of one month, and only if a replacement for their position is not required.
Leave Extension: An employee who wishes to extend a leave of absence must submit a completed Request for Leave form to his or her immediate
supervisor or department’s human resources representative at least two weeks, if practical, before the expiration date of the current leave. If the
request is for sick leave, the employee must provide documentation from their health care provider.
Leave Abridgment: An employee who wishes to abridge a leave must submit an amended Request for Leave form before returning to work and, if
the employee was on sick leave, the health care provider must certify that the employee is physically able to return to work.
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RFL (Rev.12/2020)
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