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Employee - Family Member’s Serious Health Condition

 Leave of Absence - UCLA Health Human Resources

Family Member's Serious Health Condition

Step 1) Inform your department head, manager or supervisor about taking a leave of absence as soon as possible.

Please notify your department head, supervisor or manager of your leave request 30 days prior to your anticipated leave begin date, or as soon as reasonably possible. It's best to do this as soon as your need for a leave arises, so you department can plan your absence. Try to be as specific as possible about the length of time and reasons for the leave of absence.  

Step 2) Complete your Family Member Serious Health Condition Leave of Absence Packet.

Print and complete the employee section in the Leave of Absence packet and have your physician complete the Declaration of Relationship and Health Care Provider Certification (This form should be completed and returned within 15 calendar days, if unable to do so please contact your LOA Analyst with the reasons for the delay & the date the forms will be provided). This packet should be completed when you meet with your LOA Analyst.

Step 3) Submit your Leave of Absence Notification (LOAN).

Complete and submit your Leave of Absence Notification (LOAN) and follow as instructed. This leave may be taken in an intermittent or reduced schedule basis. If you choose to take an intermittent or reduced schedule leave. Please ensure that your LOAN is approved by your supervisor/manager and by working with your LOA Analyst to complete the timesheet while you are out on leave.

Step 4) Stay in Touch.

Keep your supervisor/manager and your LOA Analyst informed of any changes or delays on your return date. If there is any need to extend your leave date, you must inform your supervisor/manager and LOA Analyst immediately by submitting a doctor's note that states your new anticipated return to work date.

Step 5) Returning to Work.

Submit your Return to Work Certification form to your supervisor/manager and LOA Analyst prior to your first day back to work. If you cancelled your benefits when you were on leave, you have 31 days from your return date to work to re-enroll by submitting a UPAY-850 to your Benefits Analyst.

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