FMLA and/or CFRA Application
FMLA and/or CFRA Qualifications:
I understand I must meet the following criterion in order to be eligible for leave under FMLA and/or CFRA and I will be notified in writing of my eligibility;

1. You must be employed by CUSD for 12 months.
2. You must have actually worked 1,250 hours in the 12 months prior to the leave (excluding all paid (sick leave and vacation) and unpaid time off. (Hours worked are verified through payroll records)
3. You have not taken 12 workweeks of FMLA and/or CFRA leave (or 26 weeks to care for an injured military service member) during the appropriate 12-month period prior to the present request.

First Name
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Last Name
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Street Address
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City
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State
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Zip
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Contact Phone Number
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Email Address (notifications will be sent via email)
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Employee ID Number
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Employee Type
Full/Part Time Employee
Position Title
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Department/Site Name
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