Notice of Family Responsibility Leave - Template Form

NOTICE OF FAMILY RESPONSIBILITY LEAVE

(Pursuant to the Employment Standards Act, 2000, S.O. 2000, c. 41, Part XIV)

FROM (Employee):

________
________
Telephone: ________
Email: ________
Employee/Payroll No.: ________
Position/Title: ________

Date: ________

TO (Employer):

________
Attention: ________
________
________

Re: Notice of Family Responsibility Leave

Dear ________,

§ 1. Purpose of Notice. Please accept this letter as my formal written notice that I am exercising my entitlement to family responsibility leave under section 50.0.1 of the Employment Standards Act, 2000, S.O. 2000, c. 41 (the “Act”). I require this leave because of an illness, injury, medical emergency or urgent matter concerning my ________, who is a family member described in subsection 50.0.1(1) of the Act.

§ 2. Statutory Entitlement. I understand that the Act provides an employee who has been employed for at least two consecutive weeks with up to three (3) days of unpaid family responsibility leave in each calendar year. I am hereby taking ________ day(s) of such leave in respect of the ________ calendar year.

§ 3. Commencement and Duration. I intend for my leave of absence to begin on ________ and, where a full day is not taken, the relevant period shall be deemed by my employer to be a full day pursuant to subsection 50.0.1(7) of the Act. I anticipate returning to work on ________.

§ 4. Documentation. Upon request, I will provide evidence reasonable in the circumstances, at a time that is reasonable in the circumstances, as proof of entitlement to this leave, in accordance with subsection 50.0.1(8) of the Act. I respectfully request that this notice be forwarded to the appropriate department to be documented and placed in my employee file.

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§ 7. Protection from Reprisal. I understand that section 74 of the Act prohibits an employer from intimidating, dismissing, penalizing or otherwise reprising against an employee for taking or proposing to take a leave to which the employee is entitled under the Act.

§ 8. Communication During Leave. If any further information regarding my leave of absence is required, please contact me by voicemail or email, and I will respond as soon as practicable. Should I be unable to respond during my leave, I plan to discuss any outstanding matters with you upon my return.

§ 9. Reservation of Rights. Nothing in this notice shall be construed as a waiver of any greater right or benefit available to me under any applicable employment contract, collective agreement, workplace policy or other applicable law, which shall continue to apply in accordance with section 5 of the Act.

Sincerely,

______________________
________
Date: ________

Acknowledgement of Receipt (Employer use):

Received by: ________
Title: ________
Date received: ________
Signature: ______________________