My leave and benefits plan (keep a copy at home)
A printable from Leave and Benefits Complete Guide. Fill it in by hand. Nothing you write is collected by this website.
My leave and benefits plan (keep a copy at home)
What happened: ________ First day I could not work: //______
My employer: business name ________ number of employees (about) ____ I have worked there since: //______
Time off (job protection)
- I asked for leave in writing on //______ and kept a copy
- Paid sick days left on my pay stub: ____ hours
- CFRA: 5 or more employees, more than 12 months, 1,250 hours? yes / no / not sure
- Pregnancy Disability Leave (5 or more employees)
- Reproductive loss or bereavement leave
Money while I am off
- State Disability Insurance. File by (49 days after first day): //______
- Paid Family Leave filed on //______
- Workers' compensation: told employer in writing on //; got DWC 1 form on //; returned it on //______
- Unemployment applied on //______ (needs work permission)
- Final paycheck received on //______ including vacation? yes / no
My papers: ID, pay stubs, provider's name and address, claim numbers ________
Phone numbers: EDD Disability 1-800-480-3287. EDD Paid Family Leave 1-877-238-4373. Workers' comp help 1-800-736-7401. Legal Aid at Work (415) 404-9093.
Do not write your immigration status on this sheet. Take it with you to a clinic.
From Leave and Benefits Complete Guide. Facts checked October 21, 2026. Free information, not legal or medical advice.