Skip to main content


CFRA Designation Notice

October 10, 2022 10104

Designation of a CFRA leave is a two-step process: employee notice of the need for a CFRA leave and employer designation of the leave as CFRA leave.

The employer must approve or deny the leave request within five days, and designate the leave as CFRA leave. This letter may be used for that purpose and to provide any additional information.


Leave covered under the California Family Rights Act (CFRA) must be designated as CFRA-protected and the employer must inform the employee of the amount of leave that will be counted against the employee’s CFRA leave entitlement. 

This form is not for use if the employee is requesting pregnancy disability leave. Please use the PDL/CFRA Designation Notice form. 

In order to determine whether leave is covered under the CFRA, the employer may request that the leave be supported by a certification (This requirement must be noted in your employer’s family and medical leave policy). 

If the certification is incomplete or insufficient, the employer must state in writing what additional information is necessary to make the certification complete and sufficient. 

While the use of this specific notice is not required, California law requires that family care and medical leave requested shall not be deemed to have been granted unless the employer provides the employee, upon granting the leave request, a guarantee of employment in the same or a comparable position upon the termination of the leave. 

Section I – Employer 

Indicate the most recent date you received a request, medical certification or other documentation of the employee's need for leave. 

Indicate whether the leave is approved or denied, or if more information is needed.  

Section II – Additional Information Needed 

If needed, indicate any additional information needed to make a leave request determination. 

Section III – CFRA Leave Approved 

If leave beginning and ending dates are known, indicate those dates in the first check box. If the length or timing of leave is not known, use the second check box. 

Indicate whether employee will be using other paid leave during CFRA. 

For CFRA leave, you may not require employees to use paid leave if the employee is receiving money through a paid disability plan such as State Disability Insurance (SDI), Paid Family Leave (PFL), workers' compensation or an employer-provided short term disability plan. Employees can choose to supplement these wage replacement benefits with paid leave. 

Use of State Disability Insurance (SDI) 

Complete this section if the employee will receive SDI benefits and has requested to supplement unpaid leave with sick leave benefits. 

Continued Health Benefits 

Employees are entitled to continued health benefits during CFRA leave for a maximum of twelve (12) weeks. Under California Law, employees on leave (PDL) will be allowed to continue to participate in group health coverage for up to a maximum of four months of PDL (if such insurance was provided before the leave was taken) on the same terms as if you had continued to work. The entitlements to employer-paid group health coverage during pregnancy disability leave and during CFRA are two separate entitlements. 

Provide the amount of money the employee must pay, the due dates and the grace period for health benefits payment. Be sure to verify the grace period with your insurance carrier. 

Return to Work 

You may require medical certification of the employee's ability to return to work if the absence is for the employee's own serious health condition. In order to require such certification, you must have a uniformly-applied policy or practice for all similar situations. The medical certification can address the employee's ability to perform the essential functions of the employee's job. If the return to work certification contains this information, you must provide the employee with a list of the essential functions of his/her job, no later than with this designation notice. 

Complete this section if you are requiring a release to return to work. Attach the essential functions of the employee's job if you want the health care provider to certify that the employee is able to perform the essential functions of his/her job upon return to work. 

Comments are only visible to subscribers.