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Letter of Critical Illness Leave - Template Form Pro · EN-CA-law

✓ Valid in Canada (English) · drafted to comply with local law

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Letter of Critical Illness Leave - Template Form
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PRIVATE AND CONFIDENTIAL

________
________
Telephone: ________
Email: ________
Employee Number: ________

________

________
Attention: ________, ________
________

Re: Notice of Critical Illness Leave under the Employment Standards Act, 2000

Dear ________:

§ 1. Purpose of Notice. Please accept this letter as my formal written notice of my intention to take Critical Illness Leave pursuant to sections 49.4 and 50.2 of the Employment Standards Act, 2000, SO 2000, c 41 (the "ESA"), as amended, and the regulations made thereunder.

§ 2. Reason for Leave. I require this leave to provide care or support to my ________, namely ________, who is a critically ill family member within the meaning of section 49.4 of the ESA. The said family member is an ________ for the purposes of determining my statutory entitlement.

§ 3. Commencement of Leave. I intend that my leave of absence commence on ________.

§ 4. Medical Certificate. A certificate issued by a qualified health practitioner, as required under subsection 49.4(3) of the ESA, was obtained on ________. The certificate states that the family member is a critically ill person who requires the care or support of one or more family members, and sets out the period during which such care or support is required. A copy of the said certificate is enclosed with this letter to establish my entitlement, and the original will be provided to you upon request as soon as is reasonably practicable.

§ 6. Duration Requested. Based on the period set out in the medical certificate, I anticipate requiring ________ weeks of leave. Should this duration exceed the minimum statutory entitlement applicable to my circumstances, I respectfully request your agreement to such extension in the form of an unpaid leave or other accommodation, and I trust that you will give this request your favourable consideration in light of my circumstances.

§ 8. Transition of Duties. I will make every reasonable effort to ensure an orderly transition of my responsibilities prior to the commencement of my leave, and I am pleased to assist with such arrangements as may be reasonably required.

§ 9. Documentation. I request that this notice and the enclosed certificate be forwarded to the appropriate department to be documented and placed in my employee file.

§ 10. Anticipated Return. I anticipate returning to work on ________. Should the circumstances giving rise to this leave change, or should I be required to end or extend my leave, I will provide you with reasonable written notice in accordance with the ESA.

§ 11. Contact During Leave. Should any further information regarding my leave be required, please contact me by telephone or email at the particulars set out above, and I will respond as soon as is reasonably practicable.

I thank you for your understanding and cooperation in this matter.

Yours sincerely,




______________________
________

Enclosure: Certificate of qualified health practitioner

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