DATE

Employee Name

Address

Dear Employee:

We are very sorry that you are ill and are very concerned about you. (Or any personalized opening that you prefer.) We are in receipt of your physician's written confirmation of disability. We are approving your absence effective ______________ through _____________.

In accordance with Personnel Policies for Staff Members (PPSM), your sick leave hours may be applied toward this period of absence. Additionally, accrued vacation may be used at your request. As of this date, you have ______ hours of sick leave and _____ hours of accrued vacation. Please 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 leave. Unless we hear from you, your unpaid leave of absence will commence on ______________ and continue through _____________.

Your time away from work effective ____________ has been preliminarily designated as Family and Medical Leave (FML). This leave entitles a qualified employee up to 12 weeks of unpaid leave in a 12-month period. 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.

In order to confirm that the leave qualifies as FML, you must provide medical certification using the enclosed form. The medical certification must be returned to this office within 15 days of the day you receive this notice.

Please submit a completed "Return to Work Certification" form (enclosed) upon your return to work.

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.

(Personalized closing).

Sincerely,
Supervisor

Enclosures

cc: Benefits and Personnel Services
Employee Relations Consultant