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California Family and Medical Leave of Absence Request Form

Author: Katherine Hinde, Littler

When to Use

An employer in California can use this form to receive employee requests for a family and medical leave of absence covered by the federal Family and Medical Leave Act (FMLA) and/or California Family Rights Act (CFRA). The form does not include non-medical leaves, including a qualifying exigency related to the covered active duty or call to covered active duty of an employee's spouse, domestic partner, child, or parent in the US Armed Forces.

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.

Customizable Form