COUNTY OF VENTURA

HUMAN RESOURCES DEPARTMENT

LEAVE OF ABSENCE REQUEST

SECTION I:

Capitalized EE
Name for
Email (Hidden):

First Name * :

Middle Name:

Last Name * :

EE ID * :

Street Address * :

City * :

State * :

ZIP Code * :

Home Phone:

Cell Phone * :

Work Phone * :

Work Email * :

Personal Email * :

Agency * :

HCA Division * :

Department * :

Last Date Worked * :

Supervisor Name * :

Supervisor Phone * :

Supervisor Email * :

Date Leave Begins * :

Date Leave Ends * :

Extension? * :

During this leave or extension, I request * :

Applying for disability benefits? * :

Type of Leave Request * :

Specify intermittent or reduced schedule * :

SECTION II:

I request a leave of absence for the following reason (check one)*:

Employee’s own serious health condition that makes the employee unable to perform the functions of his/her position.

Is the injury work related? * :

Yes

No

Injury Date * :

Do you anticipate needing accomodations when you return? * :

Yes

No

Disabled by pregnancy or childbirth.

Estimated Due Date * :

In order to care for a family member or designated person because such family member has a serious health condition.

Name * :

Relation * :

Bonding Leave

Specify * :

Date Born/Acquired * :

Military Service Leave

Emergency Rescue Personnel Leave

To assist a child, spouse, or parent who is a member of the National Guard or Reserves with a “qualifying exigency” related
to active duty or a call of active duty status in support of a contingency operation.

Specify * :

To care for a child, spouse, parent, or “next of kin” service member of the United States Armed Forces who has a serious
injury or illness incurred in the line of duty while on active duty (up to 26 weeks of leave).

Specify * :

Donor Leave

Specify * :

Personal Leave

Explain * :

Other Reason (including educational and death of family member).

Explain * :

PAOF-882-SUB (03/06/23)

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Employee Name * :

Employee ID * :

SECTION II: (CONTINUED)

Notes:

READ THE TERMS CAREFULLY BEFORE INITIALING.

I understand that:

1. I am bound by all the terms and conditions of the County’s Leave of Absence Program and that the County has the
right to grant or deny any request for a leave of absence or an extension thereof, subject by provisions of the Federal
Family Medical Leave Act, the California Family Rights Act, the California Pregnancy Disability Leave rights,
applicable collective bargaining agreements, Article 22, Section 2203 of the County of Ventura Personnel Rules and
Regulations, and the County Administrative Policy Manual.

2. I may be required to make premium payments directly to the County or its third-party administrator while on leave of
absence. If I fail to make payments on a timely basis, coverage under that benefit will be canceled until I return from
leave and deductions resume. If the County mistakenly pays any premiums on my behalf, I agree to repay the County
directly or through wage/salary deduction.

3. The failure to return to work on the day following the “Date Leave Ends” may be considered inexcusable absence
without leave and subject me to disciplinary action. I also understand that if I am absent from work without
authorization for three (3) days or two (2) consecutive twenty-four hour work shifts beginning with the day following
the “Date Leave Ends” I have entered on the front of this form, the County may deem that I have voluntarily
abandoned my job under Article 22, Section 2203, of the County of Ventura Personnel Rules and Regulations.

4. Failure to provide a complete and sufficient medical certification may result in a denial of my leave of absence
request. I further understand that I may be required to provide periodic reports on my status and intent to return to
work. I agree to notify BOTH, my supervisor and leave of absence coordinator of my availability to return to full or
restricted duty if I am released by my doctor prior to the end of an approved medical leave of absence.

5. I agree to comply with the County’s Integration policy to which employees may use approved leave bank hours in
conjunction with disability benefits that result in the employee’s full biweekly base pay. The policy prevents employees
from using leave bank hours that result in pay that is greater than their biweekly base rate. I understand that the
appropriate use of your leave bank hours must be because of and consistent with the leave granted and that I have
provided my department with payroll instructions during my leave of absence.

6. My dependent(s) eligibility for health care coverage is contingent on my submitting the proper forms within 31 days
of (1) acquiring a new dependent (birth, marriage, placement for adoption, permanent legal custody), (2) a current
dependent losing eligibility (divorce, dependent child turns age 26, death), even when the event occurs during my
leave of absence.

7. I must comply with the Flexible Benefits Program Open Enrollment rules even if I am on leave of absence. Any
applicable forms must be completed and submitted during the open enrollment period, not when I return from leave of
absence and failure to comply may jeopardize my participation.

8. I agree to notify my department of any change of address and/or phone number. I understand and agree that all
communications from the County of Ventura will be sent to the address I have on file and that I am responsible for
acknowledging information sent to the address on file.

I am bound by all the terms and conditions of the County’s Leave of Absence Program and that the County has the
right to grant or deny any request for a leave of absence or an extension thereof, subject by provisions of the Federal
Family Medical Leave Act, the California Family Rights Act, the California Pregnancy Disability Leave rights,
applicable collective bargaining agreements, Article 22, Section 2203 of the County of Ventura Personnel Rules and
Regulations, and the County Administrative Policy Manual.

I may be required to make premium payments directly to the County or its third-party administrator while on leave of
absence. If I fail to make payments on a timely basis, coverage under that benefit will be canceled until I return from
leave and deductions resume. If the County mistakenly pays any premiums on my behalf, I agree to repay the County
directly or through wage/salary deduction.

The failure to return to work on the day following the “Date Leave Ends” may be considered inexcusable absence
without leave and subject me to disciplinary action. I also understand that if I am absent from work without
authorization for three (3) days or two (2) consecutive twenty-four-hour work shifts beginning with the day following
the “Date Leave Ends” I have entered on the front of this form, the County may deem that I have voluntarily
abandoned my job under Article 22, Section 2203, of the County of Ventura Personnel Rules and Regulations.

Failure to provide a complete and sufficient medical certification may result in a denial of my leave of absence
request. I further understand that I may be required to provide periodic reports on my status and intent to return to
work. I agree to notify BOTH, my supervisor and leave of absence coordinator of my availability to return to full or
restricted duty if I am released by my doctor prior to the end of an approved medical leave of absence.

I agree to comply with the County’s Integration policy to which employees may use approved leave bank hours in
conjunction with disability benefits that result in the employee’s full biweekly base pay. The policy prevents employees
from using leave bank hours that result in pay that is greater than their biweekly base rate. I understand that the
appropriate use of your leave bank hours must be because of and consistent with the leave granted and that I have
provided my department with payroll instructions during my leave of absence.

My dependent(s) eligibility for health care coverage is contingent on my submitting the proper forms within 31 days of
(1) acquiring a new dependent (birth, marriage, placement for adoption, permanent legal custody), (2) a current
dependent losing eligibility (divorce, dependent child turns age 26, death), even when the event occurs during my
leave of absence.

I must comply with the Flexible Benefits Program Open Enrollment rules even if I am on leave of absence. Any
applicable forms must be completed and submitted during the open enrollment period, not when I return from leave of
absence and failure to comply may jeopardize my participation.

I agree to notify my department of any change of address and/or phone number. I understand and agree that all
communications from the County of Ventura will be sent to the address I have on file and that I am responsible for
acknowledging information sent to the address on file.

I affirm that I have read, understand, and agree to the terms of this request as stated above.

I have received the Leave of Absence Handbook (see LOA Handbook button) and the
informational packet (see Resources Packet button) and will be provided with appropriate
entitlement notices by the LOA Coordinator once the leave request has been processed. *

Initial Here * :

Date * :

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COUNTY OF VENTURA

HUMAN RESOURCES DEPARTMENT

LOA REQUEST - PAYROLL INSTRUCTIONS

Employee Name * :

EE ID * :

Biweekly Scheduled Work Hours * :

Last Day of Work * :

During this Leave of Absence, I request the following pay status*:

During this Leave of Absence, I request the following pay status:

During this Leave of Absence, I request the following pay status:

During this Leave of Absence, I request the following pay status:

During this Leave of Absence, I request the following pay status:

Full integration with disability benefits up to 100% of base biweekly compensation

(Required if receiving disability benefits, optional if receiving TTD)

Leave bank hours equal to total biweekly scheduled work hours

(Required if not receiving disability benefits or if disability benefits waived)

Leave without pay (LWOP) equal to total biweekly scheduled work hours

(Fully unpaid, no leave bank hours may be reported for the duration of the leave)

Partial integration with temporary total disability (TTD) benefits

(Reported hours must be consistent each pay period)

Estimated Leave Bank Balances and preference to be used during my Leave of Absence*:

Pref. #:

Current floating holiday balance:

Use all hours, as needed?:

Use Only:

Pref. #:

Current sick leave balance:

Use all hours, as needed?:

Use Only:

Pref. #:

Current vacation/annual leave balance:

Use all hours, as needed?:

Use Only:

Pref. #:

Current comp bank balance:

Use all hours, as needed?:

Use Only:

Expected Disability Benefits (check all that apply)*:

State Disability Insurance * :

Paid Family Leave

LTD (County of Ventura group plan)

Workers' Compensation

Type * :

Wage Supplement Plan

Type * :

Union Disability Plan (PORAC, other)

Notes:

To ensure proper integration with disability benefits, send a copy of your first benefit award statement to your payroll/department
representative. Please contact your payroll/department representative immediately if your disability benefit(s) amount increases,
decreases, or is terminated/exhausted.

I have read and I agree to comply with the County's integration policy to which employees may use
leave bank hours in conjunction with disability benefits that result in the employee's full biweekly base
pay. I further acknowledge that any over utilization of my leave bank balances may result in an
overpayment and I agree to repay the County of Ventura directly or through wage/salary deduction(s). *

Initial Here * :

Date * :

PAOF-882-SUB (03/06/23)

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COUNTY OF VENTURA

HUMAN RESOURCES DEPARTMENT

LOA REQUEST - WAIVER OF DISABILITY BENEFITS

Employee Name * :

Employee ID * :

If you choose not to file a claim for disability benefits with your group disability plan(s) and are requesting a paid leave, you
must read and sign this waiver, and submit it to your agency/department in advance of your leave of absence. After
receiving the signed Waiver, you will be allowed to use the appropriate hours from your leave bank balances in increments
to equal your full biweekly schedule, and until balances are exhausted or you stop authorizing leave bank usage.

By not filing a claim with your disability plan(s), you may be forfeiting a variety of benefits including but not limited to: full
and partial disability benefit payments, Return to Work Incentive payments, Reasonable Accommodation Expense
Benefits and Temporary Recovery benefits. Please note that each plan has an application deadline, after which you forfeit
all rights to benefits. Your department representative may provide a copy of this signed Waiver to your group disability
plan(s) and to County Human Resources.

I understand that leave bank usage must begin at the onset of my leave of absence. I further understand that if I change
my decision and later elect to file a claim for any group disability plan(s), I will be expected to repay the County of Ventura
and/or any group disability plan(s) that has paid me any disability benefit(s) for the same time period of this Waiver.

I have read this form and acknowledge that I understand and agree not to file for disability benefits with any group
disability plan(s) for this leave of absence. I authorize use of my leave bank balances in order to receive pay equal to my
full regular work schedule for the following period(s):

Beginning Date * :

Ending Date * :

I choose to waive benefits from the following sources indicated below*:

SDI (State Disability Insurance)

PFL (Paid Family Leave)

LTD (COV group plan)

Wage Supplement Plan

Type * :

Initial Here * :

Date * :

Keep a copy for your personal records.

PAOF-882-SUB (03/06/23)

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