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Re: Written Notice of Compassionate Care Leave
Dear ________,
§ 1. Purpose of Notice. Please accept this letter as my formal written notice that I intend to take a Compassionate Care Leave. This notice is provided to you in my capacity as an employee of ________, where I am employed in the position of ________ at the work location identified above.
§ 2. Family Member and Reason for Leave. I require this leave to provide care or support to my ________, a family member within the meaning of the applicable employment standards legislation, who has a serious medical condition with a significant risk of death within a period of twenty-six (26) weeks.
§ 3. Statutory Entitlement. This is a statutory, unpaid, job-protected leave of absence. I am taking this leave pursuant to the applicable employment standards legislation of the Province of ________, including, where applicable in Ontario, the Employment Standards Act, 2000, S.O. 2000, c. 41, as amended, and its regulations. I understand that my maximum entitlement to Compassionate Care Leave is twenty-eight (28) weeks within the applicable statutory period in respect of the same family member.
§ 4. Duration of Leave Requested. I intend for my leave of absence to begin on ________. The duration of leave I presently anticipate requiring is ________, with an expected return-to-work date of ________. I reserve my right to take additional periods of leave up to my full statutory entitlement should the circumstances continue to require it, and I will provide such further notice as the legislation requires.
§ 5. Medical Certificate. A certificate issued by a qualified health practitioner, dated ________, stating that the family member has a serious medical condition with a significant risk of death within the applicable period, is enclosed with this letter as evidence of my entitlement to this leave. I will provide such further documentation as may be reasonably required and as is permitted by law.
§ 6. Record and Filing. I respectfully request that this notice be forwarded to the appropriate department to be documented and placed in my employee file.
Sincerely,
______________________
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Date: ________
Enclosure: Certificate of Qualified Health Practitioner
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