"Leave of Absence Request Form" - Sacramento, California

Leave of Absence Request Form is a legal document that was released by the Department of Human Resources - City of Sacramento, California - a government authority operating within California. The form may be used strictly within Sacramento.

Form Details:

  • Released on September 1, 2010;
  • The latest edition currently provided by the Department of Human Resources - City of Sacramento, California;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Department of Human Resources - City of Sacramento, California.

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LEAVE OF ABSENCE REQUEST FORM
Part A - EMPLOYEE INFORMATION
1. Name (Last, First, MI)
4. Union
3. Dept ID
2. Employee ID
5. Department /Division Name
Part B- LEAVE INFORMATION
1. Leave Reason
9. If you are eligible for disability insurance
5. Current Leave Request
Attach supporting documentation
the City will automatically supplement
Start Date
End Date
Family Care
your disability insurance pay with City
pay (see reverse for more information).
Medical
Military
Please check box, if applicable
6. Expected Return
Date
Parental
I will NOT file a disability insurance
claim for this leave period.
Personal
Pregnancy Disability
7. Previous Leave
I do NOT want my disability insurance
2. Intermittent
Start Date
End Date
pay to be supplemented with my City
Yes
No
pay. I understand I will not receive pay
from the City during my leave.
3. Reduced Schedule
Yes
No
8. Please indicate the pay types you want used.
4. Is this an Extension?
Yes
No
EMPLOYEE: Please note important information on reverse side of this form!
I am aware of the Administrative Policy Instruction, and/or Civil Service Board
Employee Signature
Date
rules governing this leave. I am also aware of the provisions in the labor
agreement or Unrepresented Personnel Resolution covering my position
which pertains to this leave.
Part C - PERSONNEL ACTION / DEPARTMENT APPROVAL
1. Effective Date
2. Does the employee qualify for City Parental Pay or Pregnancy Disability Pay?
No
PAR
PGD
160 hours
80 hours
4. Department Authorization (Name, Title, Signature, Date)
3. PAR Processor (Name, Title, Signature, Date)
Approved
Denied at Department
Pending HR Approval
Date
Date
Part D - REMARKS
Part E - HR USE
Initials/Signature
Date
Division/Function
Director of Human Resources Signature (Required if Over 90 days)
E&C
A)
Leave Admin
B)
Date:
Leave Administration Policy
Page 1 of 2
LEAVE OF ABSENCE REQUEST FORM
Part A - EMPLOYEE INFORMATION
1. Name (Last, First, MI)
4. Union
3. Dept ID
2. Employee ID
5. Department /Division Name
Part B- LEAVE INFORMATION
1. Leave Reason
9. If you are eligible for disability insurance
5. Current Leave Request
Attach supporting documentation
the City will automatically supplement
Start Date
End Date
Family Care
your disability insurance pay with City
pay (see reverse for more information).
Medical
Military
Please check box, if applicable
6. Expected Return
Date
Parental
I will NOT file a disability insurance
claim for this leave period.
Personal
Pregnancy Disability
7. Previous Leave
I do NOT want my disability insurance
2. Intermittent
Start Date
End Date
pay to be supplemented with my City
Yes
No
pay. I understand I will not receive pay
from the City during my leave.
3. Reduced Schedule
Yes
No
8. Please indicate the pay types you want used.
4. Is this an Extension?
Yes
No
EMPLOYEE: Please note important information on reverse side of this form!
I am aware of the Administrative Policy Instruction, and/or Civil Service Board
Employee Signature
Date
rules governing this leave. I am also aware of the provisions in the labor
agreement or Unrepresented Personnel Resolution covering my position
which pertains to this leave.
Part C - PERSONNEL ACTION / DEPARTMENT APPROVAL
1. Effective Date
2. Does the employee qualify for City Parental Pay or Pregnancy Disability Pay?
No
PAR
PGD
160 hours
80 hours
4. Department Authorization (Name, Title, Signature, Date)
3. PAR Processor (Name, Title, Signature, Date)
Approved
Denied at Department
Pending HR Approval
Date
Date
Part D - REMARKS
Part E - HR USE
Initials/Signature
Date
Division/Function
Director of Human Resources Signature (Required if Over 90 days)
E&C
A)
Leave Admin
B)
Date:
Leave Administration Policy
Page 1 of 2
THE INFORMATION GIVEN BELOW IS IMPORTANT.
PLEASE BE SURE TO READ IT CAREFULLY!
Leaves of Absences must be reported to the Department of Human Resources when: an employee is absent from duty Medical,
Family Care, Pregnancy Disability or Parental Leave reasons for three (3) or more consecutive working days continuously or on a
reduced schedule, an employee is absent intermittently for Medical, Family Care, Pregnancy Disability or Parental Leave
r e a s o n s , or an employee is absent from duty for more than 20 consecutive working days for Military or Personal Leave reasons.
It is your responsibility to submit requests for leave, or extensions of leave, as soon as the need is known, however, it is the
department's responsibility to report leaves to the Department of Human Resources. Since you could be liable for benefits you
are not entitled to if the leave is not properly processed, or could fail to receive certain statutory benefits to which you may be
entitled, it is imperative that your leave request is promptly forwarded to the Department of Human Resources.
A medical certificate must accompany all Medical, Family Care and Pregnancy Disability leave requests. In the case of Parental
leave, proof of birth or adoption must be submitted. A copy of military orders must be attached to a military leave request.
Paid leave accruals may not be spread out by taking time without pay during several pay periods to avoid interruption of benefits.
The City may continue health and welfare benefits contributions during unpaid leave in accordance with the Leave Administration
Policy. In addition, you may be eligible for benefits under the Family and Medical Leave Act (FMLA) and/or California Family
Rights Act (CFRA) or, if on military service leave, you may be eligible for benefits under the Military and Veterans Code or other
applicable laws. In the event you are not entitled to health and welfare benefits during your leave, please contact the
Department of Human Resources, Human Resources Division, at 808-5665 to continue or withdraw from your health and welfare
benefits. For information on the FMLA, CFRA, the Military and Veterans Code, or other applicable laws, please contact the
Department of Human Resources, Administration Division, Leave Administrator at 808-8249.
Employees on a Medical, Family Care, Pregnancy Disability, or Parental Leave and who are eligible for disability insurance will
have their disability insurance pay automatically supplemented with available City pay (such as accrued sick, vacation or other
City pay such as parental pay). If the employee files a disability insurance claim they may elect not to supplement the disability
insurance pay and go without pay (WOP). If the employee elects not to supplement disability insurance pay, the employee will
not be paid by the City. The employee will be responsible to reimburse the City for any applicable benefit cost. If an employee
does not file a disability claim, they will be required to utilize their available City pay resulting in receipt of 100% of base wages.
You must contact your department before your leave expires either to make arrangements to return to work or to request an
extension of leave. Inexcusable failure to report to work upon expiration of approved leave is considered an automatic
resignation. Be sure to read Civil Service Board Rule 10, as well as any related language in the current labor agreement or
Unrepresented Personnel Resolution, which covers your position. If you are requesting military leave, you should also read Civil
Service Board Rule 17.
As a condition of returning to work, an employee who was on Medical or Pregnancy Disability Leave must obtain and present
certification from the Health Care Provider that the employee is able to resume work. The certification must be no more than 10
days old and state that the employee is able resume work with or without reasonable accommodation. The certification must
specify any limitations that may require reasonable accommodation.
If your medical leave exceeds six months, family care leave exceeds four months or personal leave exceeds 90 days, your
position may be filled. If your position has been filled and there is no vacant position in the same classification in your
department, your department will notify the Department of Human Resources to place your name on a reinstatement list per Civil
Service Board Rule 10.
If you have any questions, call the Department of Human Resources, Administration Division, Leave Administrator at 808-8249.
Leave Administration Policy
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