HomeMy WebLinkAboutOCDSB 451C Statutory Leave Request form 2022Statutory Leave Request Form
Employment Standards Act
Employee Name: ______________________________
Location: ____________________________________
EIN: ________________
Date: _______________
The Ontario Employment Standards Act, 2000 (“the ESA”) provides eligible employees the right to
take job-protected leaves of absence from their job for certain reasons. The ESA provides the eligibility
criteria, the individuals for whom a leave may be taken, the length and timing of a leave, the types of
health care professionals who may complete the medical certificate, and other requirements for each
type of leave. The heading of each leave, below, contains a link to the ESA description and
entitlements.
I am applying for the following leave:
❏Family Caregiver Leave: To provide care or support to certain individuals who have a serious
medical condition. Does not qualify for Employment Insurance.
❏Family Medical Leave (EI Compassionate Care): To provide care or support to certain individuals who have a serious medical condition with a significant risk of death within a period of 26 weeks. May qualify for Employment Insurance and SEB Plan.
❏Critical Illness Leave for a Child (EI Family Caregiver Leave for Children): To provide care or
support to a critically ill or injured child. May qualify for Employment Insurance and SEB Plan.
❏Critical Illness Leave for an Adult (EI Family Caregiver Leave for Adult): To provide care or
support to a critically ill or injured adult. May qualify for Employment Insurance and SEB plan.
❏Domestic or Sexual Violence Leave: To seek medical attention or to access services when an
employee or an employee’s child has experienced or been threatened with domestic or sexual
violence. First five days are paid, however, does not qualify for Employment Insurance.
❏Child Death Leave: Unpaid, job protected leave of up to 104 weeks. Does not qualify for Employment Insurance.
❏Crime-related Child Disappearance Leave: Unpaid, job protected leave of up to 104 weeks.
Does not qualify for Employment Insurance; may qualify for Federal Income Support for Parents.
❏Infectious Disease Emergency Leave: If an employee is not performing the duties of their
position because of specified reasons related to COVID-19 they may be eligible for this unpaid job
protected leave. May qualify for Employment Insurance.
OCDSB 451C Jan 2022 Page 1 of 2
Please complete both pages before submitting to Human Resources.
Statutory Leave Request Form
Employment Standards Act
Please provide the name of the person and the relationship to you as it relates to the leave you
are requesting. Note: You may be required to provide a medical certificate or documented
evidence to support your request.
Name: ______________________________________________
Relationship: ______________________________________________
Please provide additional details to support this leave request:
_________________________________________________________________________________
_________________________________________________________________________________
I am requesting this leave for the following dates:
From: ____________________
YYYY/MM/DD
To: ____________________
YYYY/MM/DD
Signature: _____________________________ Date: ____________________
OCDSB 451C Jan 2022 Page 2 of 2
•To apply for Employment Insurance (EI) visit www.canada.ca/en/services/benefits/ei.html
•If the leave you require is eligible for Employment Insurance Benefits, you may be entitled to the
Supplemental Employment Benefit (SEB) to top up your income for up to eight (8) weeks. In
order to receive the SEB Plan payment, you must apply for EI and provide proof of eligibility (for
top up to 100%) or ineligibility (for 100%) to the Payroll Department.
•Confirmation of approval from EI must be submitted to Payroll and HR Staffing in order to
receive a SEB Plan payment.
•Please return this completed form to your Human Resources Administrator and keep a copy for
your records.
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