Forms

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Forms

Title Short Description Topic Campus
Catastrophic Leave - Donation Form (Exhibit C)

Form through which employees who wish to donate their accrued vacation leave to colleague who have exhausted their own leave options. 
Submit to: Department Supervisor, Manager or Chief Administrative Officer

Leave/Time-Off UC Davis and UC Davis Health Download
Catastrophic Leave - Request for Donations (Exhibit B)

Email template for departments to use to notify employees of a colleague’s request for Catastrophic Leave donations.
Submit to: Department employees

Leave/Time-Off UC Davis and UC Davis Health Download
Exceed Maximum Vacation Accrual Limit Request

Managers and employees can use this form to when the employee exceeds the vacation accrual threshold.
Submit to: Department Head, then ELR

Leave/Time-Off UC Davis Download
FML/PDL Intermittent Tracking Form

Assists departments in tracking intermittent usages of family medical leave (FML) or pregnancy disability leave (PDL).
Submit to: For department use only

Leave/Time-Off UC Davis and UC Davis Health Download
FMLA Certification for Leave Arising out of Active Duty

For employees requesting FML for a covered military member being called to active duty.
Submit completed form to: Leave Team

Leave/Time-Off UC Davis and UC Davis Health Download
FMLA Certification of Health Care Provider for Employee's Own Condition

For employees requesting FML or CFRA for themselves, this form documents their qualifying condition.
Submit completed form to: Leave Team

Leave/Time-Off UC Davis and UC Davis Health Download
FMLA Certification of Health Care Provider for Family Member

For employees requesting FML or CFRA to care for a family member, this form documents the family member's qualifying condition.
Submit completed form to: Leave Team

Leave/Time-Off UC Davis and UC Davis Health Download
FMLA Declaration of Relationship

Employees are eligible for family medical leave for certain life events that impact relatives. This form helps ensure the relationship is FML eligible.
Submit completed form to: Leave Team

Leave/Time-Off UC Davis Download
FMLA Military Caregiver Leave Certification

Employees are Eligible for protected leave to care for the serious injury or illness of a covered service member.
Submit completed form to: Leave Team

Leave/Time-Off UC Davis and UC Davis Health Download
FMLA Request Department Checklist

Helps departments who aren't under a Shared Services Center to manage employee leave requests.
Submit to: For department use only. 

Leave/Time-Off UC Davis Download
FMLA Return to Work Certification

Employee completes with health care provider and returns completed form to their department, allowing employee to return to work after FML.
Submit completed form to: Leave Team

Leave/Time-Off UC Davis and UC Davis Health Download
Leave of Absence Request

Form that UC Davis Health employees can use to request an extended leave of absence for certain life events.
Submit to: Manager and/or department personnel liaison.

Leave/Time-Off UC Davis Health Download
Non-Financial Leave Hours Adjustment

For Department personnel liaisons and payroll to submit form to adjust an employee’s leave hours.
Submit to: Payroll

Leave/Time-Off UC Davis and UC Davis Health Download
OnBase Form

Complete to record a leave of absence.
Submit to: Shared Services Organization, UC Davis Health Records Unit

Leave/Time-Off UC Davis Health Download
Paid Leave Chart

Compensation options for employees on paid leave.

Leave/Time-Off UC Davis Health Download
Pay Status During Leave

UC Davis Health employees should use this form to indicate their pay status during leave.  Submit to: LOA Services Department/UCDH

Leave/Time-Off UC Davis Health Download
PDL Certification of Health Care Provider

This form provides the medical certification to support your request for PDL due to pregnancy, childbirth, or related medical condition.

Submit to: After completion by employee and health care provider; then submit to department personnel.

Leave/Time-Off UC Davis and UC Davis Health Download
Staff Leave Request

Staff may use form to request leave using vacation, sick, comp time, leave without pay, supplemental family medical leave, or personal leave.
Submit to: Department Manager

Leave/Time-Off UC Davis Download
Supplement to Military Pay

Active duty military personnel can receive supplemental compensation.
Submit to: UC Davis - If leave is managed by a Shared Services team, please send to the appropriate office otherwise, please provide to your supervisor.
UC Davis Health - submit to: hs-hrrecords@ucdavis.edu

Leave/Time-Off UC Davis and UC Davis Health Download