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California Family and Medical Leave Notice of Eligibility and Rights and Responsibilities Form

Author: Katherine Hinde, Littler

When to Use

When an employee requests time off that qualifies or may qualify as leave under the Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA), the employer must notify the employee whether they are eligible for FMLA leave within five business days of the employee's request. Each time an employer must provide the eligibility notice to an employee, it must also provide an FMLA rights and responsibilities notice. This form may be used to inform employees of their eligibility for, and rights and responsibilities under, the FMLA, the CFRA and California's Pregnancy Disability Leave (PDL) law.

Employer coverage under these laws are as follows:

  • The FMLA covers employers that employ 50 or more employees in 20 or more workweeks in the current or preceding calendar year that are engaged in commerce or in any industry or activity affecting commerce.
  • The CFRA covers employers that directly employ five or more employees.
  • California's pregnancy disability leave law covers employers that employ five or more full- or part-time employees for each working day in 20 consecutive calendar weeks in the current calendar year or preceding calendar year, regardless of whether the employee's worksite is located within or outside of California.

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