California CFRA Leave Request Form: Filing, Certification, and Denials

There is no official statewide California CFRA leave request form. The California Civil Rights Department does not publish one, so most employees submit the request on their employer’s internal HR form. If your employer does not have a form, a written request — an email is fine — works as long as it identifies you, states a qualifying reason, and gives the dates you need. Your employer then has five business days to respond.¹

Where to Get the Form

Start with your HR department or employee portal. Many California employers use their own leave request document that collects everything they need in a single step, and state agencies typically route employees through internal templates like CalHR’s forms. The only template the Civil Rights Department publishes is the Certification of Health Care Provider, which your doctor completes separately.²

If HR has nothing to give you, write your own request. There is no required format. What matters is that the document contains the information described in the next section, and that you can prove when you sent it.

What to Put in the Request

Whether you use your employer’s form or write your own, the request should cover four things:

Your identifying information: full name, employee ID, job title, department, and contact details.
The qualifying reason: your own serious health condition, care for a family member with a serious health condition (and your relationship to that person), or bonding with a new child after birth, adoption, or foster placement.
The dates you need: expected start date, expected end date, and total duration. For intermittent leave, describe the anticipated frequency and length of each absence.
Whether the need for leave is foreseeable: a scheduled surgery, an expected birth, or a pre-arranged placement is foreseeable; a sudden hospitalization or emergency is not.

If you are requesting leave to care for someone outside the usual list of relatives, CFRA recognizes a “designated person” — someone related to you by blood or in a relationship equivalent to a family bond. Identify that person by name in the request. Your employer can limit you to one designated person per 12-month period.³ CFRA’s list of covered family also includes a child of any age, spouse, domestic partner, parent, grandparent, grandchild, and sibling.⁴

You do not have to mention “CFRA” by name. If your employer has enough information to recognize a qualifying reason, it is the employer’s job to designate the absence as CFRA leave.¹ Naming the law anyway removes any ambiguity.

When to Submit It

For foreseeable leave, give your employer at least 30 days’ advance notice. You are also expected to schedule planned medical treatment at times that minimize workplace disruption, subject to your provider’s approval.⁵

For unforeseeable leave — an emergency room visit, a sudden decline in a family member’s condition — notify your employer verbally as soon as you learn of the need, then follow up in writing. Missing the notice rules can give your employer grounds to defer the start of your leave until you comply.⁶

The Medical Certification That Goes With It

If your leave is for a serious health condition, yours or a family member’s, your employer can require a Certification of Health Care Provider. The Civil Rights Department publishes a version in English and Spanish; some state employers use CalHR Form 754 instead.²⁷

The provider confirms the date the condition began, its probable duration, and the medical facts that make leave necessary. The form does not require disclosure of your specific diagnosis, and the instructions tell the provider not to include it without your consent.⁷ If the leave is for your own condition, the provider indicates whether you can perform your essential job functions. If it is for a family member, the provider confirms that the condition warrants your participation in providing care.⁸

If your employer has a good-faith, objective reason to doubt a certification for your own serious health condition, it can require a second opinion at the employer’s expense, from a provider it does not regularly employ. Second opinions are not allowed when the certification is for a family member’s condition.⁹

Bonding leave does not require a medical certification. Your employer can ask for reasonable documentation of the birth, adoption, or placement.

How to Submit It and What Happens Next

Deliver the request and any certification through a channel that gives you proof of receipt. An HR portal with a digital timestamp is ideal. For paper documents, hand-deliver and get a signed acknowledgment, or send by certified mail with return receipt. A clean paper trail matters if a dispute arises later.

Once the employer has your request, it must respond as soon as practicable and no later than five business days, ideally before your leave is scheduled to begin. If approval comes after your leave has already started, it applies retroactively to the first day.¹ An employer generally cannot wait until you have returned to work and then designate the absence as CFRA leave, unless doing so causes you no harm.

Check Your Eligibility Before You File

Three conditions must all be true for CFRA to protect your leave. You need more than 12 months of service with your employer (not necessarily consecutive), at least 1,250 hours worked in the 12 months immediately before your leave starts, and your employer must have five or more employees.¹⁰ The five-employee floor is well below the 50-employee threshold for federal FMLA, so many California workers qualify for state leave even when they are not covered federally.⁴

Extended absences or part-time hours in the 12 months before your leave can push you below the 1,250-hour cutoff, so check that math before assuming you qualify.

If Your Leave Is for Pregnancy

Pregnancy itself is not a qualifying serious health condition under CFRA, so a straight CFRA request is not the right form. California handles pregnancy through Pregnancy Disability Leave, which provides up to four months for the period you are actually disabled by pregnancy or childbirth. When that disability period ends, you can then submit a CFRA request for up to 12 workweeks of bonding leave, back to back with PDL.¹¹ You do not need to show a serious health condition for the CFRA bonding portion.

Pay While You Are Out

CFRA is unpaid. The form protects your job, not your paycheck. Wage replacement comes from a separate program, California’s Paid Family Leave, administered by the Employment Development Department. PFL pays roughly 70 to 90 percent of your weekly wages up to a maximum of $1,765 per week, and covers bonding leave and leave to care for a seriously ill family member.¹² For your own medical condition, you would apply instead for State Disability Insurance through the same agency.

PFL requires its own application through EDD; filing your CFRA leave request does not trigger it. Your employer can require CFRA and PFL to run concurrently.¹³

Health Insurance and Coming Back to Work

While you are out, your employer must maintain your group health coverage — including dental, vision, mental health, and dependent coverage — at the same level as if you were still working, for up to the 12-workweek maximum. If your leave is unpaid, the employer can require you to keep paying your share of the premium and must tell you in writing how and when to do so.¹⁴

When your leave ends, your employer must reinstate you to the same position or a comparable one with similar duties, pay, and location. Seniority, tenure, and benefits keep accruing as though you never left.¹⁰

If the Request Is Denied or You Face Retaliation

It is unlawful for an employer to interfere with, restrain, or deny CFRA rights. That covers firing or demoting someone who requests leave, and it covers subtler moves after you return: cutting hours, reassigning you to a worse shift, or passing you over for promotion because of the absence.¹⁰

If your leave is wrongly denied or you believe you have been retaliated against, you can file a complaint with the California Civil Rights Department, and you may have the right to bring a private lawsuit. Keep copies of your leave request, the employer’s response, all medical certifications, and related communications. The medical documents themselves must be stored separately from your personnel file and treated as confidential.

1
New York Codes, Rules and Regulations. California Code of Regulations Title 2 Section 11091 – Requests for CFRA Leave
2
California Civil Rights Department. Job-Protected Leave for Employees in California
3
New York Codes, Rules and Regulations. California Code of Regulations Title 2 Section 11087 – Definitions
4
California Civil Rights Department. Family Care and Medical Leave: Quick Reference Guide
5
Legal Information Institute. California Code of Regulations Title 2 Section 11091 – Requests for CFRA Leave
6
Legal Information Institute. California Code of Regulations Title 2 Section 11095 – Notice of CFRA Rights
7
California Department of Human Resources. CalHR 754 – Certification of Health Care Provider for Employee’s Serious Health Condition
8
California Civil Rights Department. CFRA Certification Health Care Provider
9
California Department of Human Resources. California Family Rights Act – Human Resources Manual
10
California Legislative Information. California Code GOV 12945.2 – Family Care and Medical Leave
11
New York Codes, Rules and Regulations. California Code of Regulations Title 2 Section 11046 – Relationship Between CFRA and Pregnancy Leaves
12
Employment Development Department. Paid Family Leave Benefit Payment Amounts
13
Employment Development Department. Family and Medical Leave Act and California Family Rights Act FAQs
14
elaws.us. California Code of Regulations Title 2 Section 11092 – Terms of CFRA Leave