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"Family and Medical Leave Forms - Archdiocese of Los Angeles" - Los Angeles, California
Family and Medical Leave Forms - Archdiocese of Los Angeles is a legal document that was released by the California Department of Fair Employment & Housing - a government authority operating within California. The form may be used strictly within Los Angeles.
Form Details:
- Released on January 1, 2013;
- The latest edition currently provided by the California Department of Fair Employment & Housing;
- 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 printable version of the form by clicking the link below or browse more documents and templates provided by the California Department of Fair Employment & Housing.
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13ARCHDIOCESE OF LOS ANGELES
LEAVE OF ABSENCE POLICY
FAMILY AND MEDICAL LEAVE
Revised 2013
Family and Medical Leave is a leave of absence, taken without salary or wages, for incapacity
due to pregnancy, pregnancy related conditions, prenatal medical care or childbirth; to care for a
child after birth, or placement for adoption or foster care; to care for a spouse, son or daughter,
legally domiciled adult or parent who has a serious health condition; or for a serious health
condition that makes the employee unable to perform his or her job.
A serious health condition is an illness, injury, impairment, or physical or mental condition that
involves either an overnight stay in a medical care facility, or continuing treatment by a health
care provider for a condition that either prevents the employee from performing the functions of
the employee’s job, or prevents the qualified family member from participating in school or
other daily activities.
An employee with a serious health condition involving a period of incapacity of more than three
consecutive calendar days may take a leave of absence provided eligibility requirements are met.
Eligibility
Regular full-time and regular part-time employees who are regularly scheduled to work at least
20 hours/week in any job classification and have been employed by the Archdiocese at any
Archdiocesan location for at least 12 months preceding the leave are eligible for family and
medical leave.
The 12 months of employment need not be consecutive, provided that the
continuous break in service is not more than seven years. However, employees are eligible for
pregnancy disability leave, per pregnancy, at any time after date of hire, regardless of minimum
hours worked or length of service. Eligibility for family care leave for the birth of a child,
adoption or placement of a foster child expires 12 months from the birth, adoption or placement
date.
Maximum Length of Leave
The maximum length of Family and Medical Leave is four months (16 weeks) of leave within
any 12 month period. The 12 month period for Family and Medical Leave is measured forward
from the date the employee begins his or her FMLA leave. For example, an employee whose
initial leave of absence begins on May 1, 2009 may take up to 4 months FMLA leave during the
12 month period between May 1, 2009 and April 30, 2010; with eligibility for another 4 months
FMLA effective May 1, 2010.
ARCHDIOCESE OF LOS ANGELES
LEAVE OF ABSENCE POLICY
FAMILY AND MEDICAL LEAVE
Revised 2013
Family and Medical Leave is a leave of absence, taken without salary or wages, for incapacity
due to pregnancy, pregnancy related conditions, prenatal medical care or childbirth; to care for a
child after birth, or placement for adoption or foster care; to care for a spouse, son or daughter,
legally domiciled adult or parent who has a serious health condition; or for a serious health
condition that makes the employee unable to perform his or her job.
A serious health condition is an illness, injury, impairment, or physical or mental condition that
involves either an overnight stay in a medical care facility, or continuing treatment by a health
care provider for a condition that either prevents the employee from performing the functions of
the employee’s job, or prevents the qualified family member from participating in school or
other daily activities.
An employee with a serious health condition involving a period of incapacity of more than three
consecutive calendar days may take a leave of absence provided eligibility requirements are met.
Eligibility
Regular full-time and regular part-time employees who are regularly scheduled to work at least
20 hours/week in any job classification and have been employed by the Archdiocese at any
Archdiocesan location for at least 12 months preceding the leave are eligible for family and
medical leave.
The 12 months of employment need not be consecutive, provided that the
continuous break in service is not more than seven years. However, employees are eligible for
pregnancy disability leave, per pregnancy, at any time after date of hire, regardless of minimum
hours worked or length of service. Eligibility for family care leave for the birth of a child,
adoption or placement of a foster child expires 12 months from the birth, adoption or placement
date.
Maximum Length of Leave
The maximum length of Family and Medical Leave is four months (16 weeks) of leave within
any 12 month period. The 12 month period for Family and Medical Leave is measured forward
from the date the employee begins his or her FMLA leave. For example, an employee whose
initial leave of absence begins on May 1, 2009 may take up to 4 months FMLA leave during the
12 month period between May 1, 2009 and April 30, 2010; with eligibility for another 4 months
FMLA effective May 1, 2010.
Exceptions to 16 Week Leave Maximum
The Archdiocese provides Pregnancy Disability Leave for up to 18 weeks leave per pregnancy
for pregnancy related conditions. After completion of Pregnancy Disability Leave, the employee
may take Family Care Leave of up to 12 additional weeks to bond with their child.
Military Caregiver Leave provides that eligible employees may take up to 26 weeks of leave to
care for a covered servicemember during a single 12 month period.
Required Certification for Leave
The length of the leave is determined and certified in writing by a physician and is not to exceed
the leave maximum designated for the type of leave taken. The employee is required to inform
his or her supervisor of the status of the leave and any changes in the expected date of return.
The supervisor or department head should notify the appropriate administrator, i.e., Pastor,
Principal, or Human Resources (for ACC/Cemeteries employees) of any changes in the
employee's return date. Employees not returning to work on the date in the physician's release
may be considered to have voluntarily resigned unless other arrangements have previously been
made.
Pregnancy Disability Leave
The Archdiocese provides Pregnancy Disability Leave for up to 18 weeks leave per pregnancy
for pregnancy related conditions. After completion of Pregnancy Disability Leave, the employee
may take Family Care Leave of up to 12 additional weeks to bond with their child.
Employees are eligible for pregnancy disability leave, per pregnancy, at any time after date of
hire. There is no eligibility requirement, such as minimum hours worked or length of service,
before an employee affected or disabled by pregnancy is eligible for reasonable accommodation,
transfer or disability leave.
A woman may take up to 18 weeks leave for pregnancy disability based on the number of days
or hours the employee is normally scheduled to work. For example, a full time 40 hour/week
employee, 18 weeks is equivalent to (18weeks x 40 hrs/wk) or 720 hours of leave. For a part-
time 20 hour/week employee, 18 weeks is equivalent to (18 weeks x 20 hrs/wk) or 360 hours of
leave.
Covered pregnancy conditions include pregnancy, childbirth or related medical conditions
including, but not limited to, “morning sickness”, lactation related medical conditions such as
mastitis; gestational diabetes; pregnancy induced hypertension; preeclampsia; post-partum
depression; loss or end of pregnancy or recovery from loss or end of pregnancy.
Pregnancy disability leave must be certified by a note from their physician or other appropriate
health care provider.
2
Family Care Leave
After completing her pregnancy disability leave, a woman may take up to an additional three
months (12 weeks) of Family Care Leave to stay home and bond with her child. Leave to care
for the child shall be no more than 12 weeks when taken in conjunction with 18 weeks
pregnancy disability leave. Family Care Leave for baby bonding is unpaid, but the employee
may use any accrued vacation pay.
Benefits During Pregnancy Disability Leave and Family Care Leave.
An employee is eligible for up to 18 weeks of benefits coverage during Pregnancy Disability
Leave and up to 12 additional weeks of benefits coverage during Family Care Leave for a
maximum of up to 30 weeks. The employee is responsible for their regular premium cost and
must make arrangements with their administrator to pay premiums.
Spouses who are both employed at the same Archdiocesan location are limited to a total of four
months Family and Medical Leave for the birth, adoption or foster care of a child, or to care for a
seriously ill parent.
Reinstatement after Pregnancy Disability Leave and Family Care Leave
The employee returning from Pregnancy Disability Leave or a combined Pregnancy
Disability/Family Care Leave is guaranteed a right to return to the same position, or under
certain circumstances, to a comparable position.
Intermittent Leave
Intermittent or reduced leave is permitted if medically necessary for serious health condition of
parent, child, spouse, legally domiciled adult, or self as certified by a physician. Only the
amount of time the employee takes off can be counted as FMLA leave. Employees must make
reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the
employer’s operations.
End of Term Leave Requirements for Schools
Instructional employees of Archdiocesan schools may be required to continue taking leave until
the end of a school term under the following conditions:
1) If leave begins more than five weeks before the end of the term and leave is at least 3 weeks
long and return to employment would occur during the 3 week period before end of the term;
3
2) If leave begins less than 5 weeks before the end of the term and leave is more than 2 weeks
long and return would occur during the 2 weeks before end of the term;
3) If leave begins less than 3 weeks before the end of the term and leave is more than 5 working
days and return would occur less than 2 weeks before the end of the term.
Employee Notice Requirement
Employees requesting Family and Medical leave must observe the same call in procedures as for
sick time, but in addition to notifying their immediate supervisor, they should contact the
appropriate administrator, i.e., Pastor, Principal, or Human Resources (for ACC/Cemeteries
employees) to file their request for a leave of absence.
Procedure to Request Leave
Complete the Leave of Absence Request form and submit to supervisor/department head and the
appropriate administrator, i.e., Pastor, Principal, or Human Resources (for ACC/Cemeteries
employees) for approval at least 30 days in advance of foreseeable leave (i.e., birth of child,
adoption) or with as much advance notice as is practicable.
Employees are required to provide certification and periodic recertification supporting the need
for the leave. For leave to care for an ill parent, spouse, legally domiciled adult, child or self,
provide a written statement from the physician certifying:
• The date on which the serious health condition commenced;
• The duration of condition;
• Appropriate medical facts;
• That the employee is needed to care for the seriously ill individual; or that the employee
is unable to perform the functions of the position;
• An estimate of amount of time employee is needed to care for the family member.
• If requesting leave to care for a servicemember (Military Caregiver Leave), you must
provide a written statement from a U.S. Department of Defense (DOD) authorized health
care provider or Veterans Affairs health care provider confirming that the covered
servicemember’s injury or illness was incurred in the line of duty on active duty and
requires care.
• In order to return to work, all employees returning from medical leave must present a
doctor’s note fully releasing them to return to work. If your doctor releases you to return
to work with any restrictions, a decision about your return to work will be evaluated
4
based on the list of essential job duties. You must present the doctor’s full release
confirming your fitness for duty and ability to perform the essential job functions before
you can return to work.
Benefits
While on family and medical leave, an employee's group insurance coverage will continue at the
employee’s regular premium cost for a period of four months (16 weeks).
Exceptions:
Pregnancy Disability Leave and Family Care Leave: An employee is eligible for up to 18 weeks
of benefits coverage for pregnancy related disability and up to 12 additional weeks of benefits
coverage during Family Care Leave to bond with their child.
Military Caregiver Leave: An employee is eligible for up to 26 weeks benefits coverage while
taking Military Caregiver Leave to care for a covered servicemember. Leave maximum is 26
weeks during a single 12 month period.
The employee is responsible for making these premium payments to the appropriate
administrator, i.e., Pastor, Principal, or the Insurance Department (for ACC/Cemeteries
employees).
According to the Consolidated Omnibus Reconciliation Act (COBRA) if the employee is still
disabled or does not return to work after four months, he or she may continue their medical
insurance for 18 months, but is responsible for the cost of the entire premium plus an
administrative fee. Mail premium payments directly to the health insurance administrators.
Should an employee fail to return after the end of the leave for a reason other than the
continuation, recurrence or onset of a serious health condition which would entitle them to
FMLA leave or other circumstances beyond their control, the employee may be liable for unpaid
portions of insurance premiums.
FMLA Leave is unpaid, but employees may use any accrued vacation or sick time, where
applicable, during leave. This paid time off will be counted against your FMLA leave
entitlement.
Employees who have elected voluntary disability insurance coverage, may choose to apply for
their disability benefit if they are taking a leave of absence for their own illness. Employees
receiving disability payments cannot simultaneously receive sick or vacation pay.
5
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