How to Complete the Request for Review (Campus Accommodation and/or Medical Separation) Form

Protected leaves, also referred to as Family Medical Leave (FML), consist of the Family and Medical Leave Act (FMLA), California Family Rights Act (CFRA) and Pregnancy Disability Leave (PDL).

Click on the links to find out more about these protected leaves:

• Your Rights Under FMLA, CFRA, and PDL
• FMLA/CFRA Guidelines
• Pregnancy Disability Leave

NOTE:
FMLA/CFRA – the employee is not eligible if the employee does not have one year of service (it does not have to be consecutive) and 1250 hours actually worked in the 12 months preceding the need for leave. PDL does not have eligibility requirements, other than being pregnant; therefore, all pregnant employees are eligible.

• The employee has a serious medical condition an¬d cannot perform one or more of their essential job functions. The employee meets the eligibility requirements for FMLA/CFRA (1 year of service and 1250 actual hours worked in the past 12 months). The employee has been out on FML from 2/1/12 – 4/30/2012.

Supplemental Family and Medical Leave is an entitlement for PPSM employee's whose need for a family and medical leave that is in progress continues beyond 12 work weeks.

In this case, a regular status employee shall be entitled to supplemental leave for up to 12 work weeks or until the end of the leave year, whichever is less.

Learn more about Supplemental Family and Medical Leave.

• The employee is represented by a collective bargaining agreement and not eligible for Supplemental Leave.

• PPSM employee has a serious health condition and cannot perform the essential job functions. The employee is out on a medical leave for 12 work weeks from 2/1/11 – 4/30/11. The health care provider submits additional medical documentation that the employee's serious health condition continues and the employee will need to be off work through 7/24/11. The employee is placed on Supplemental Leave from 5/1/11 – 7/24/11.

Workers' Compensation is a state-mandated insurance plan designed to provide benefits and assistance to employees who are injured as a result of their employment or who develop a work-related illness.

Disability Management Services coordinates this benefit for the campus.

NOTE:
Workers' Compensation cases submitted for medical review must be discussed with Disability Management Services (DMS).

• There are no pending workers' compensation claims.

Work restrictions and duration of those restrictions are provided by the employee's health care provider. Once received, review the documents from the health care provider and enter the most recent work restrictions and the duration of those restrictions in the box. Attach the documentation to the form.

• The employee provides you with a letter from their health care provider with restrictions that prevent the employee from performing the essential functions of the job for three months (6/11/11 – 9/1/11). You receive a second health care provider letter extending the duration of the restrictions for six more months (9/1/11 - 3/1/12). Attach copies of both health care provider letter to the review form and file the letters in the employee's medical file.

The essential functions of a position should already be noted on the job description. If they are not, consider the following:

• The fundamental job duties of the position.
• The position exists to perform this function.
• There would be serious consequence if this function was not performed.

Learn more about Essential Job Functions.

The interactive process is a good faith on-going communication process between the supervisor (or appropriate designee) and employee to identify potential reasonable accommodation(s) for work restrictions that will allow the employee to perform the essential functions of the job. Disability laws require that employers and employees engage in the Interactive Process.

Learn more about interactive process and department obligations.

• On 1/5/11, the supervisor met with the employee to discuss work restrictions and possible accommodations that would allow the employee to return to work. The supervisor spoke with the employee again on 1/15/11 regarding possible accommodations.

A reasonable accommodation is a modification or an adjustment to a job or the work environment that will enable the employee or qualified applicant with a disability to perform the essential job functions. Accommodations can include physical alterations to the work environment, shift changes, leave of absence, and many others.

In this step, it is important that you document all accommodations offered, provided, considered, and those requested by the employee but not provided. Provide a narrative with details and dates and outcomes where appropriate.

Learn more in Policies and the Guide to Managing Human Resources.

Employees must be notified, in writing, prior to requesting the review of campus accommodation or medical separation.

Briefly summarize (be specific) the reasons why the department is requesting this review.