CFRA Leave Request (California)

# CFRA Leave Request (California) This form documents an employee's request for leave under the California Family Rights Act. It is submitted to Human Resources for designation and processing. --- ## Part A — Employee Information **Full Legal Name:** ___________ **Employee ID / Personnel Number:** ___________ **Department:** ___________ **Job Title:** ___________ **Manager / Supervisor Name:** ___________ **Work Email:** ___________ **Work Phone:** ___________ **Date of Hire:** ___________ **Number of Employees at Your Worksite or Within 75 Miles (if known):** ___________ --- ## Part B — CFRA Eligibility Self-Assessment CFRA requires that you have worked for your employer for at least 12 months and have worked at least 1,250 hours in the preceding 12 months. Your employer must have at least 5 employees. **Have you worked for this employer for at least 12 months?** ___________ **Have you worked at least 1,250 hours in the past 12 months?** ___________