Leaves Forms

Form

Description

Campus

Catastrophic Leave - Application
UC Davis Health employees should use this form to apply for catastrophic leave.
Submit to: Department Manager or Chief Administrative Officer.
UC Davis Health
Catastrophic Leave - Worksheet
Managers and Chief Administrative Officers complete this form when considering an employee’s request for catastrophic leave.
Submit to: ELR for review and determination.
UC Davis Health
Catastrophic Leave - Medical Information Release (Exhibit A)
In the event that an employee has donated their leave to a colleague, this form allows the university to release a general medical description to support the employee's catastrophic leave request.
Submit to: Department Supervisor
UC Davis
Catastrophic Leave - Request for Donations (Exhibition B)
Form through which employees can donate leave time to fellow employees who have exhausted their personal leave options.
Submit to: Department Employees
UC Davis
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
UC Davis
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
UC Davis
FML 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 to: Department personnel
UC Davis / UC Davis Health
FML Employee Checklist Helps employees work through the process of requesting family medical leave for certain life events.
Submit to: For employee use only.
UC Davis
FML Request, Department Checklist Helps departments who aren't under a Shared Services Center to manage employee leave requests.
Submit to: For department use only. 
UC Davis
FML 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 to: Employee completes with health care provider and returns completed form to their department.
UC Davis / UC Davis Health
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
UC Davis / UC Davis Health
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 to: After completion by employee, family member, and family member's health care provider; then submit to department personnel
UC Davis / UC Davis Health
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 to: After completion by employee, family member, and family member's health care provider; then submit to department personnel
UC Davis / UC Davis Health
FMLA Certification for Leave Arising out of Active Duty
For employees requesting FML for a covered military member being called to active duty.
Submit to: Department
UC Davis / UC Davis Health
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 to: Department personnel
UC Davis / UC Davis Health
FMLA, CFRA, Pregnancy Disability Leave Designation Notice
Allows departments to document if an employee's FML, CFRA, or PDL request has been approved.
Submit to: Department completes form and submits to employee. 
UC Davis / UC Davis Health
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.
UC Davis Health
Non-Financial Leave Hours Adjustment Form For Department personnel liaisons and payroll to submit form to adjust an employee’s leave hours.
Submit to: Payroll
UC Davis / UC Davis Health
OnBase Form Complete to record a leave of absence.
Submit to: Shared Services Organization, UC Davis Health Records Unit
UC Davis Health
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.

UC Davis / UC Davis Health
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
UC Davis
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
UC Davis / UC Davis Health