DATE

Employee Name

Address

Dear Employee:

This is to confirm that you are eligible for Family and Medical Leave (FML) and that the leave of absence you requested on __________ has been preliminarily designated as FML.

In order to confirm that the leave qualifies as FML, you must provide a doctor's certification. The medical certification must be returned to this office within 15 days of the day you receive this notice. Once we receive such certification, this designation will become final. If you do not provide medical certification, or if, for any reason, it does not support the request for Family and Medical Leave, this preliminary designation will be withdrawn and you will be notified. Failure to provide the medical certification means that the leave is not FML and, at the department's discretion, your leave may be canceled or designated as a personal leave.

You currently have _____ hours of accrued sick leave and _____ hours of vacation. After providing the medical certification, please also provide us with a short note, as soon as possible, advising us if you wish to apply your accrued vacation hours to any portion of your absence. Unless we hear from you, your unpaid leave of absence will commence on ______________ and continue through _____________.

For your information, I have enclosed several information items including "Your Rights and Obligations Under the Federal Family and Medical Leave Act of 1993," a "Family and Medical Leave Benefits Checklist," and applicable portions of Personnel Policies for Staff Members, Policy 43, regarding FML.

If you have any questions regarding your leave and associated entitlements and obligations, you may contact your Employee Relations Consultant at (310) 794-0860. If you have any questions regarding the continuation of employee benefits during your leave of absence, you may contact Benefits and Personnel Services at (310) 794-0830.

Sincerely,
Supervisor

Enclosures

cc: Benefits and Personnel Services
Employee Relations Consultant