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Request for Medical Leave or Family Medical Care Leave of Absence

  1. 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].

  2. Employee Information
  3. Leave Information
  4. 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].

  5. 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.

  6. Please indicate which disability plan you will be applying for. 

  7. 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. 

  8. Leave This Blank:

  9. This field is not part of the form submission.