Disability Management Forms & Templates

What's on this Page

• Pregnant Workers Fairness Act Accommodation
• Lactation Accommodation Request Form
• Covid-19 Exposure and Reporting
• Medical Leaves
• Temporary Transitional Duty
• Permanent Restrictions -Reasonable Accommodation
• Workers' Compensation
• Military Leave
• Catastrophic Leave
• Pre-Employment Self Disclosure
• Reproductive Loss Leave Accommodation Form
• Reproductive Loss Leave Letter Template

Pregnant Worker (PWFA) Accommodation Letter
(Word®: 35.5 kB)

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Lactation Accommodation Request Form
(PDF: 175.81KB)

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Forms

• Quick COVID-19 Positive Tracking Form
  (Word®: 29.6KB)

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Medical leave provides eligible employees up to 12 weeks of job protected unpaid leave.

Learn more about Medical Leave

For Employees

• Medical Certification Form Self-Caregiver
  (PDF: 2.34 MB)
• Request for Leave of Absence Form
  (PDF: 206 kB)
• Employee Medical Leave Checklist
  (PDF: 152 kB)

For Departments and Liaisons

• Notice of FMLA and CFRA Rights and Responsibilities Form
  (PDF: 133.87 KB)
• Department Medical Leave Checklist
  (PDF: 136 kB)

Letter Templates

• Medical Leave Approval, Self or Caregiver FMLA and CFRA Eligible
  (Word®: 23.9 kB)
• Medical Leave Approval, not FMLA and CFRA eligible
  (Word®: 31 kB)
• Pregnancy Leave Approval, FMLA and CPDL eligible
  (Word®: 14 kB)
• Pregnancy Leave Approval, not FMLA eligible
  (Word®: 15 kB)
• Bonding Leave Approval, CFRA eligible
  (Word®: 14 kB)
• Clarification needed on Restrictions - Self
  (Word®: 34 kB)
• Request for Updated Medical Certification
  (Word®: 14 kB)
• Second Request for Updated Medical Certification
  (Word®: 15 kB)
• Clarification needed on Medical Certification to determine FMLA and CFRA eligibility - Self
  (Word®: 31 kB)
• Clarification needed on Medical Certification to determine FMLA and CFRA eligibility - Family Member
  (Word®: 31 kB)

For situations not covered by the templates above, please reach out to your assigned Disability Management Analyst.

• Disability Management Analyst Assignment Chart
  (PDF: 178.52 KB)

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The purpose of the Temporary Transitional Duty Program (TTrD) is to provide early intervention for those injured or ill employees who are expected to return to full duty. 

Learn more about Temporary Transitional Duty

• Accommodation Request / Certification Form
  (PDF: 1.35MB)

Letter Templates

• Occupational Injury/Illness Temporary Transitional Duty Assignment
  (Word®: 33.5 kB)
• Non Occupational Temporary Transitional Duty Assignment
  (Word®: 14.8 kB)
• Temporary Transitional Duty Not Available
  (Word®: 23.5 kB)

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A reasonable accommodation is any modification or adjustment to a job or the work environment that will enable a qualified applicant or employee with a disability to participate in the application process or to perform essential job functions.

Learn more about Reasonable Accommodation

• Accommodation Request / Certification Form
  (PDF: 1.35MB)

Letter Templates

• Initial notification of Interactive Process
  (Word®: 15.7 kB)
• Permanent Restrictions Accommodation 
  (Word®: 15.8 kB)
• Permanent Restrictions No Accommodation
  (Word®: 27.5 kB) 

Pre-Employment Permanent Restrictions Letter Templates

• Pre-Employment Permanent Restrictions Accommodation 
  (Word®: 15.8 kB)
• Permanent Restrictions No Accommodation
  (Word®: 27.5 kB)

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The County of Sonoma's Workers’ Compensation Program compensates employees for disability leave and medical treatment as a result of a work-related injury or illness.

Learn more about Workers' Compensation

For Supervisors

• Supervisor’s Report of Occupational Injury / Illness / Exposure
  (PDF: 171 kB)
• Instructions for Completion of the Supervisors Report
  (PDF: 56 kB)
• Accident/Incident Investigation Report
  (PDF: 225 kB)
• Instructions for Completion of Accident/Incident Report 
  (PDF: 87 kB)

Letter Templates

• Occupational Injury/Illness Temporary Transitional Duty Assignment
  (Word®: 33.5 kB)
• Temporary Transitional Duty Not Available
  (Word®: 23.5 kB)

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Military Leave is available to all County employees including Extra Help employees who perform service in the uniformed services. Military Leave may be covered under FMLA/CFRA and administered accordingly. Please reach out to your Disability Management Analyst for guidance.

• Disability Management Analyst Assignment Chart
  (PDF: 178.52 KB)

Learn more about Military Leave

• Medical Certification for Covered Service Member 
  (PDF: 184 kB)
• Certification for Qualifying Exigency for Military FMLA
  (PDF: 145 kB)

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Self-Disclosure of Restrictions and/or Need for Accommodation Form
(PDF: 101 kB)

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Reproductive Loss Leave Accommodation Form
(PDF: 225.78 kB)

Reproductive Loss Leave Letter Template
(Word®: 28.69kB)
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Catastrophic Leave Request Form
(PDF: 32.31 kB)

Decedent's Leave Benefit Request Form
(PDF: 27.08 kB)

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