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.) As you may be aware, your leave may qualify 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.

Your time away from work is being preliminarily designated as FML, effective today. 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. Once your eligibility is confirmed, we will notify you and this designation will become final. If the certification is not provided, or if the certification for any reason does not support the request for FML, this preliminary designation will be withdrawn and you will be notified. Failure to provide the certification means that the leave is not FML, and, at the department's discretion, your leave may be canceled or designated as personal leave.

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