GCBDA/GDBDA-AR(7) – Designation Notice

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

In order to determine whether leave is covered under the OFLA, the district may request that the leave be supported by a physician’s certification. If the certification is incomplete or insufficient, the district will state in writing what additional information is necessary to make the certification complete and sufficient.

Employee Name: Date:

We have reviewed your request for leave under the OFLA and any supporting documentation that you have provided. We received your most recent information on (date).

Please be advised:

• □ Your request is approved for OFLA. All leave taken for this reason will be designated as OFLA leave.

The OFLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. Based on the information you have provided to date, we are providing the following information about the amount of time that will be counted against your entitlement:

• □ Provided there is no deviation from your anticipated leave schedule, the following number of hours, days or weeks will be counted against your leave entitlement:

• □ Because the leave you requested will be rescheduled, it is not possible to provide the hours, days or weeks that will be counted against your OFLA entitlement at this time. You have the right to request this information once in a 30-day period (if leave was taken in the 30-day period).

Please be advised (check if applicable):

• □ You have requested to use paid leave during your OFLA leave. Any paid leave taken for this reason will count against your OFLA leave entitlement.

• □ We are requiring you to substitute or use paid leave during your OFLA leave.

• □ You will be required to present a fitness-for-duty certification to be reinstated to your position. If such certification is not timely received, your return to work may be delayed until certification is

provided. The Fitness-for-Duty Certification form is attached, please have your medical provider complete this form prior to the termination of your leave. A list of the essential functions of your position □ is □ is not attached. If attached, the fitness-for-duty certifications must address your ability to perform these functions.

• □ Additional information is needed to determine if your OFLA leave request can be approved.

• □ The certification you have provided is incomplete and insufficient to determine whether the OFLA applies to your leave procedures. You must provide the following information no later than (date) (at least 15 calendar days), unless it is not practicable under the particular circumstances despite your diligent good faith efforts, or your leave may be denied. The information needed to make the certification complete and sufficient is:

• □ We are exercising our right to have you obtain a second or third opinion medical certification at our expense, and we will provide further details at a later time.

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• □ Your OFLA leave request is NOT APPROVED.

• □ The OFLA does not apply to your leave request.

• □ You have exhausted your OFLA leave entitlement in the applicable 12-month period.