Date
Employee Name
Employee Address
City, State Zip
Dear :
<CHARTER SCHOOL> has received medical certification indicating that you are [will become] disabled due to pregnancy as of [DATE]. You are not eligible for FMLA/CFRA because:
_____ You have not met the 12-month length of service requirement. As of the first date of requested leave, you will have worked approximately ______months towards this requirement.
_____ You have not met the 1,250 hours-worked requirement. As of the first date of requested leave, you will have worked approximately ______hours towards this requirement.
_____ You are considered to be a “Key” employee and FML would create grievous economic damage.
_____ Other: state reason
Under state law, you are entitled to pregnancy disability leave (PDL) of up to 17-13/ weeks (693 hours) if you are a full time employee, if you are disabled because of pregnancy, childbirth, or other related medical condition. You previously have used ______[days / hours] of pregnancy disability leave and thus the total remaining pregnancy disability leave available to you is ______[days / hours].
According to the medical certification, you should be able to return to work on [DATE]. Please notify us of your return to work date as soon as possible. If your doctor has not released you on that date, you will need to provide us with further medical documentation of your need for additional leave.
School policy (allows/requires) use of paid sick leave during pregnancy disability leave. You currently have [NUMBER OF HOURS] hours of accrued sick leave. The sick time (may/will) be paid out beginning on your first day of absence. If you are eligible for state disability insurance (SDI), your SDI benefits will be reduced by that amount.
During your pregnancy disability leave, you may take any accrued and unused vacation/PTO hours. You currently have [NUMBER OF HOURS] hours available to you. Please advise [NAME OF SCHOOL CONTACT] if you wish to use any of your vacation time during your pregnancy disability leave.
Your medical benefit coverage will continue during your pregnancy disability leave for up to 17-1/3 weeks in a 12-month period commencing on the date the leave begins. If you currently contribute to the payment of benefits, you must continue to do so while on leave. Your portion of medical benefits is $______per month which will be due and payable on the first day of the month following commencement of your leave. You will submit payment to:
Remember that you must provide the school with a medical release to return to work form or certification from your doctor of continued disability on or before the date the prior certification expires.
Enclosed with this letter are the following documents:
_____ DFEH Pregnancy Disability Leave Brochure
_____ DFEH Notice “A”
_____ EDD “For Your Benefit” Brochure re SDI benefits
_____ DFEH Paid Family Leave Brochure
If you have any questions about pregnancy disability leave or other benefits, please contact:
School Representative
Address
City State Zip
Phone #
Email Address