Steps to Follow

EMPLOYER CHECKLIST

For Medical Leave of Absence due to Employee’s Own Illness

(Non FMLA/CFRA Employer)

Steps to follow / Date given to employee (employer completes) / Form Name
Form # / Action
Necessary / Required timeframe to issue to employee / Purpose of Form
#1
□ / Date
______/ Leave of Absence Request Form
(Non FMLA/CFRA Employer)
(Form #4701) / Ask employee to complete when requesting time off
Date Returned
______/ Immediately when employee requests time off / To request time off for employee’s ownmedical leave of absence;employer to respond via Form #4801 which explains process of leave and responsibilities
#2
□ / Date
______/ Response to Your Request for aMedical Leave of Absence for Your Own Illness
(Form #4801) / Employer completes the form when the employee requests a leave of absence for theirown illness / Suggest 10 business days from the date the employee requests the leave / Explains the leave and the employee’s responsibilities during the leave of absence
#3
□ / Date
______/ Return-to-Work certification (Form #4515) / Give to employee if you will require it before an employee can return from leave / Recommend at the same time as Response to Your Request for a Medical Leave of Absence form is given to employee / Provides assurance that employee is fit for duty and able to perform essential job functions
#4
□ / Date
______/ Medical Certification for Serious Health Condition for Employee (Non FMLA/CFRA Employer)
(Form #4802) and Authorization for Release of Medical Information / Give to employee requesting leave if s/he does not have acceptable medical certification; attach a copy of the employee’s job description
Date Returned / Suggest 10 business days from receipt of LOA request;suggest employee returns to employer within 15 calendar days / Medical provider certification of serious health condition requiring employee to take a medical leave of absence for employee’s own illness
#5
□ / Date
______/ EDD Disability Insurance pamphlet / Give pamphlet to employee who is requesting a medical leave of absence / Recommend immediately when employee requests time off / Provides an explanation of the disability benefits available as a wage replacement through the EDD for time off of work due to a personal medical condition
When medical leave exhausted and employee needs additional leave continue to #6
#6
□ / Date
______/ Leave of Absence Request Form (Form #4701) / Ask employee to complete when requesting extended leave after exhausted prior unpaid medical leave / Give to employee within two (2) weeks of exhausting prior unpaid medical leave / To request time off for employee’s own medical leave of absence; employer to respond via Form #4801 which explains process of leave and responsibilities
#7
□ / Date
______/ Extended Unpaid Medical Leave Letter (Form 4803) – (If extended leave approved) / Give to employee upon approving additional unpaid medical leave / Give to employee within five (5) days of approved extended leave / Explains extended unpaid medical leave and the employee’s responsibilities during the leave of absence