You have
Disability Management Unit
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 Workers Fairness Act Accommodations
Lactation Accommodation Request Form
Covid-19 Exposure and Reporting
On January 9, 2024, Cal OSHA and CDPH updated their COVID-19 isolation guidance. The County is providing the following important information to employees in accordance with the most recent updates.
Forms
- Contact Tracing Spreadsheet
(PDF: 237 kB) - Quick Covid Positive Contract Tracing
(PDF: 194 kB)
Letters
- Letter 2A: Vaccinated Close Contact Notification
(Word®: 38 kB) - Letter 2AA: Vaccinated Close Contact Notification
(Word®: 39 kB) - Letter 3: Leave and Resource Information for Covid Positive Employees
(Word®: 42 kB) - Letter 4: Non-Employee Notice of Potential Exposure to Covid-19
(Word®: 37 kB)
Medical and Bonding Leave Forms and Templates
Medical leave provides eligible employees up to 12 weeks of job protected unpaid leave.
Learn more about Medical Leave
For Employees
- Medical Certification for Employees
(PDF: 194 kB) - Medical Certification for Family Members
(PDF: 187 kB) - Request for Leave of Absence Form
(PDF: 206 kB) - Employee Medical Leave Checklist
(PDF: 152 kB)
For Departments and Liaisons
- Notification of Eligibility and Entitlements of Family Medical Leave
(PDF: 104 kB) - Department Medical Leave Checklist
(PDF: 136 kB)
Letter Templates
- Medical Leave Approval, FMLA and CFRA eligible - Self
(Word®: 16 kB) - Medical Leave Approval, FMLA and CFRA eligible - Family Member
(Word®: 16 kB) - Medical Leave Extension Approval, FMLA and CFRA eligible
(Word®: 16 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) - Intermittent Leave Approval - Self
(Word®: 14 kB) - Intermittent Leave Approval - Family Member
(Word®: 14 kB) - Return to Work Confirmation
(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)
Temporary Transitional Duty Forms and Templates
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
For Employees
- Medical Certification for Employees
(PDF: 194 kB) - Request for Leave of Absence Form
(PDF: 259 kB) - Employee Medical Leave Checklist
(PDF: 152 kB)
For Departments and Liaisons
- Notification of Eligibility and Entitlements of Family Medical Leave
(PDF: 104 kB) - Department Medical Leave Checklist
(PDF: 136 kB)
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)
Permanent Restrictions & Interactive Process (IAP) Forms and Templates
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
For Employees
- Medical Certification for Employees
(PDF: 194 kB) - Request for Leave of Absence Form
(PDF: 259 kB) - Employee Medical Leave Checklist
(PDF: 152 kB)
For Departments and Liaisons
- Notification of Eligibility and Entitlements of Family Medical Leave
(PDF: 104 kB) - Department Medical Leave Checklist
(PDF: 136 kB)
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)
Workers' Compensation Forms and Templates
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)
For Employees
- Medical Certification for Employees
(PDF: 194 kB) - Request for Leave of Absence Form
(PDF: 259 kB) - Employee Medical Leave Checklist
(PDF: 152 kB)
For Departments and Liaisons
- Notification of Eligibility and Entitlements of Family Medical Leave
(PDF: 104 kB) - Department Medical Leave Checklist
(PDF: 136 kB)
Letter Templates
- Occupational Injury/Illness Temporary Transitional Duty Assignment
(Word®: 33.5 kB) - Temporary Transitional Duty Not Available
(Word®: 23.5 kB) - Medical Leave Approval, FMLA and CFRA eligible - Self
(Word®: 16 kB) - Medical Leave Extension Approval, FMLA and CFRA eligible
(Word®: 16 kB) - Medical Leave Approval, not FMLA and CFRA eligible
(Word®: 31 kB) - Intermittent Leave Approval - Self
(Word®: 14 kB) - Return to Work Confirmation
(Word®: 14 kB)
Military Leave Forms and Templates
Military Leave is available to all County employees including Extra Help employees who perform service in the uniformed services.
Learn more about Military Leave
For Employees
- Medical Certification for Covered Service Member
(PDF: 184 kB) - Certification for Qualifying Exigency for Military FMLA
(PDF: 145 kB) - Request for Leave of Absence Form
(PDF: 259 kB) - Employee Medical Leave Checklist
(PDF: 152 kB)
For Departments and Liaisons
- Notification of Eligibility and Entitlements of Family Medical Leave
(PDF: 104 kB) - Department Medical Leave Checklist
(PDF: 136 kB)
Letter Templates
- Medical Leave Approval, FMLA and CFRA eligible - Self
(Word®: 16 kB) - Medical Leave Extension Approval, FMLA and CFRA eligible
(Word®: 16 kB) - Medical Leave Approval, not FMLA and CFRA eligible
(Word®: 31 kB)