Benefits

Leaves and Disabilities

Short -Term Disability

Type	Name
	DE-4S State Income Tax Withholding STD
	Job Action Request (JAR)
	Disability Overpayment Recovery Letter
	Leave Request for Extended Sick & Special Leave & Leave Integrations forms (both must be completed)
	W-4S Federal Income Tax Withholding STD

State Disability Insurance

Type	Name
	Claim for Disability Insurance Benefits (DE 2501)
	Leave Request for Extended Sick & Special Leave & Leave Integrations forms (both must be completed)

Workers’ Compensation

Type	Name
	Employee Claim Form (DWC-1)
	Employer’s Report of Occupational Injury or Illness (5020)
	First Aid Record
	Medical Service Order (MSO)
	Occupational Injury/Illness Personal Physician Request
	Workers' Compensation Codes Change Request
	Leave Request for Extended Sick & Special Leave & Leave Integrations forms (both must be completed)

NOTE: A new RESSL is not needed if you ONLY need to update your leave integration, you can skip to page 2 and fill out just the Leave Integration form.

Family Medical Leave Act (FMLA) and CA Family Rights Act (CFRA)

Type	Name
	Leave Request for Extended Sick & Special Leave & Leave Integrations forms (both must be completed)
	FMLA Tracking

Medical Emergency Leave (MEL)

Type	Name
	MEL Request Form
	MEL Permission to Advertise
	MEL Attending Physician Statement
	MEL Agreement to Donate Leave Time
	MEL Release of Information

Other Leave

Type	Name
	Revised (COVID-19) Voluntary Time Off (VTO)
	Voluntary Time Off