Form Center

2. Family and Medical Care Leave Request

   This form is to be completed by an employee for any leave of three or more days related a serious medical condition, caring for a qualifying family member with a serious medical condition, or bonding with a new child. The Supervisor may complete this form on the employee's behalf if they have sufficient information. 

   Following receipt of this form, Human Resources will contact the employee with additional information.

   Please direct any questions to Human Resources at 707.257.9505 or [email protected]

6. Employee Information
8. Employee First Name*
9. Employee Last Name*
11. Phone Number*
12. Personal Email Address
16. Leave Information
18. Start Date of Leave
    Start Date of Leave
19. Return Date From Leave
    Return Date From Leave
21. Purpose of Leave*
    -- Select One --Medical - SelfMedical - Qualifying Family MemberPregnancy Disability (and New Child Bonding if eligible)New Child Bonding (including adoption and foster care)Military Family - Qualifying ExigencyMilitary Family - Injured Service Member
23. Qualifying Family Member*
    -- Select One --SpouseRegistered Domestic PartnerChildParentSibling

    Indicate qualifying family member which you will be taking leave for.

25. Type of Leave Requested*
    -- Select One --ContinuousIntermittent
27. Required Documentation

    You may be required to provide medical documentation to support your leave. If you have documentation that you would like to submit as part of this request, please email it to [email protected]

29. Paid Leave Options*

    Per the City of Napa Family and Medical Care Leave Administrative Regulation, employees are required to use and exhaust their accrued leave concurrently with family and medical care leave with the exception of employees on disability plans that pay a portion of their salary while on leave.

    If you qualify, please indicate if you plan on applying for a disability plan such as State Disability Insurance (SDI) and/or Paid Family Leave (PFL). Please select all that apply.

    1. Not applicable - using accrued leave
    2. SDI with integration
    3. SDI without integration
    4. PFL with integration
    5. PFL without integration
    6. Other disability plan with integration
    7. Other disability plan without integration
31. Other Disability Plan

    Please indicate which disability plan you will be applying for. 

35. Notification

    You are responsible for communicating your need for leave with your Supervisor. This form initiates your leave request with Human Resources and will be reviewed by your immediate Supervisor and Department Director. 

37. Your Supervisor *
    -- Select One --Administrative Battalion Chief BerensRobert "Dean" HannaBattalion Chief CorteseBattalion Chief GilbertWarren CraigBattalion Chief RhodesCaptain BaraccoCaptain BecerraCaptain BeckerCaptain BurgessCaptain CaldwellCaptain ChamnessCaptain CronbachCaptain CroweElizabeth CroweCaptain D'AngeloCaptain DavisCaptain DombrowskiCaptain JonesCaptain KochCaptain LangfordCaptain MortimoreCaptain OlivaSamuel GlennCaptain VoglerGreg FortuneShuree EgloffMichael BarretSteve PotterTony ValadezJoy RiesenbergHernando GuillemJason WilliamsLark FerrellSabrina FloresMike DombrowskiJason BerensZach CurrenStephanie GaulSteve PotterVincent SmithBret PrebulaElizabeth CabellLauri ZiebarthAnette HeunScott NielsenSheila EsserTracy ThompsonMJ TuerosKen RutherfordChuck SamsonJose AlvarezBrian DonahueBrandon AlvesCaitlin SaldanhaJessie GoochSara Gallegos-AscencioJoanne FabiaTiffany CarranzaAlexandra "Ali" KoenigDan OppermanDavid YoudellDerek TrayaHannah RamirezLiz HabkirkSarah FreemanJeffrey GittingsJohn HeddermanKatrina GregoryKelly AbernathyLinda ButtonPeter "Pete" HangenAlfonso OrtizAndrew "Andy" HessBrian CampagnaChase HaagGary PitkinGus UllothHeath MorrisonImelda PreciadoJennifer GonzalesKristofer JennyMichael "Mike" WalundNicholas DalessiPeter "Pete" PiersigRobert PlummerEdward "Ed" MooreHeather MaloneyJose "Joe" GallegosJoseph CarrionJulie Lucido Julio Carillo-ElizaldeLawrence "Larry" JanesMagdiel FrayreJeff FreitasAfton PinneyMichael BergerPeter BrestakRichard HansenTerry FongRosalba RamirezTimothy WoodDon SchmidtChristopher "Chris" ShoopDavid HightDouglas De MasterErin KebbasJoy EldredgeKevin MillerPatrick CostelloKimberly RicePhilip "Phil" BrunKen HurstSabrina WolfsonRobert JanowskiVincent WildermanJosh StokesDavid C. JonesAlexander IslerBecky Abrams

    You Supervisor will receive this request.

39. Department*
    -- Select One --Julie Lucido - Public WorksHeather Ruiz - Human ResourcesAnne Cardwell - FinanceVin Smith - Community DevelopmentJennifer Gonzales - Police DepartmentPhil Brun - UtilitiesSteve Potter - City ManagerZach Curren - Fire Department

    Your Director will receive this request.

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field