Protected Leave

​The City of Salem shall adhere to federal and state governing laws regarding protected leave.

Protected leaves include but are not limited to:

  • Military Leave
  • Family Medical Leave
  • Oregon Family Medical Leave
  • Oregon Victims of Certain Crimes Leave
  • Peace Corp Leave

​Process to complete for protected leave

  1. Complete and sign the Protected Leave Application Form HR 017.
  2. Complete the Protected Leave Authorization for Release of Health Information Form HR 018.
  3. Take or send the FMLA (Family Medical Leave Act)/OFLA (Oregon Family Leave Act) Certification of Health Care Provider form to your/patient's health care provider or as instructed based upon your protected leave request.

Please note:

  • Medical certification is not required for birth/adoption/foster child UNLESS there are medical circumstances resulting in the need for time that are directly related to the pregnancy.
  • Some certifications are from Legal entities and or DOD authorized doctors.   

To determine which protected leave you will be applying for, please look over the information in the tables below.

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Employee/Self

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Complete form HR 018 Protected Leave Authorization for Release of Health Information
4
Submit forms HR 017 and HR 018 to the Human Resource Department
5
Complete and take to your medical provider form HR 019 Certification of Health Care Provider for Employee's Serious Health Condition
6
Submit completed HR 019 form to the Human Resource Department
7
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave
8
Prior to returning to work you must provide form HR 026 Release to Return to Work to the Human Resources Department

Family Member - Spouse, Parent, Child Under 18 (OFLA only, Parent-in-law, Same-sex Domestic Partner, Child over 18, Grandparent or Grandchild)

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Complete form HR 018 Protected Leave Authorization for Release of Health Information
4
Submit forms HR 017 and HR 018 to the Human Resource Department
5
Complete and take to your medical provider form HR 020 Certification of Health Care Provider for Family Member's Serious Health Condition
6
Submit completed HR 020 form to the Human Resource Department
7
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave
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Pregnancy Disability (can be intermittent or reduced schedule - can be pre and post birth)

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Complete form HR 018 Protected Leave Authorization for Release of Health Information
4
Submit forms HR 017 and HR 018 to the Human Resource Department
5
Complete and take to your medical provider form HR 019 Certification of Health Care Provider for Employee’s Serious Health Condition
6
Submit completed HR 019 form to the Human Resource Department
7
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave

** A female who takes leave for a pregnancy-related disability, including routine pre-natal care may take up to an additional 12 weeks for any other qualifying purpose. Additional leave may be OFLA only, depending on how many weeks used of pregnancy disability.

Leave switches from pregnancy disability to parental leave upon medical release from the health care provider.

Parental Leave - Birth, Adoption or Placement of Foster Child (can NOT be intermittent or reduced schedule)

 

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Complete form HR 018 Protected Leave Authorization for Release of Health Information
4
Submit forms HR 017 and HR 018 to the Human Resource Department
5
Complete and take to your medical provider form HR 019 Certification of Health Care Provider for Employee’s Serious Health Condition
6
Submit completed HR 019 form to the Human Resource Department
7
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave

** Employees who use a full 12 weeks of parental leave may use up to 12 additional weeks in the same year for sick child leave.

Under certain circumstances, a female could potentially qualify for 36 weeks of leave during one year:

12 weeks OFLA/FMLA pregnancy disability

12 weeks OFLA/FMLA parental leave

12 week OFLA sick child leave

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Exigency Leave - Spouse, Parent, or Child

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Submit form HR 017 to the Human Resource Department
4
Complete Form HR 021 Certification of Qualifying Exigency for Military Family Leave
5
Submit completed HR 021 form to the Human Resource Department and active duty orders
6
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave

Serious Injury/Illness of a Current Service Member/Veteran (in the line of duty) - Spouse, Parent, Child, or Next of Kin

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Complete form HR 018 Protected Leave Authorization for Release of Information
4
Submit forms HR 017 and HR 018 to the Human Resource Department
5

Complete and take to your medical provider the form HR 022 or HR 023

- HR 022 Certification for Serious Injury or Illness of a Current Service Member

- HR 023 Certification for Serious Injury or Illness of a Veteran

6
Submit completed HR 022 or HR 023 form to the Human Resource Department
7
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave
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Non-serious health condition (can be intermittent or reduced schedule)

** If illness/injury is serious, follow the procedures for Serious Health Condition as outlined above.
** If illness/injury is NON-serious, employer or employee follows procedures below:
1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Complete form HR 018 Protected Leave Authorization for Release of Information
4
Submit forms HR 017 and HR 018 to the Human Resource Department
5
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave
6
After third occurrence employee must complete and take to your medical provider Form HR 020 Protected Leave Certification of Health Care Provider for Employees Serious Health Condition
7
Submit completed HR 020 form to the Human Resource Department
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Domestic Violence Related

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Submit form HR 017 and document to certify reason for leave (i.e. police report, letter from attorney) to the Human Resource Department
4
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave

Leave to Attend Criminal Proceedings (can be intermittent or reduced schedule)

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Submit form HR 017 and document to certify reason for leave (i.e. police report, letter from attorney) to the Human Resource Department
4
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave
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Spouse, Parent, Child, Parent-in-law, Same-Sex Domestic Partner, Grandparent or Grandchild

1
Down load form HR 016 Protected Leave Instructions
2
Complete form HR 017 Protected Leave Application
3
Submit form HR 017 to the Human Resource Department
4
Human Resources will provide to you form HR 024 Protected Leave Notice of Eligibility and HR 025 Rights and Responsibilities for Taking Protected Leave
** Entitled to two weeks of leave per occurrence but no more than 12 weeks per protected leave year.

Completing the process

The following steps must be completed after you have determined which type of leave you will be requesting and filled out the proper forms.

Return all completed forms to the Human Resource Department.

  • Forms may be mailed or delivered to 555 Liberty St. SE, Room 225, Salem OR 97301, or faxed to our attention.
  • The Human Resource fax number is 503-588-6170. Make sure the health care provider marks the fax as confidential.

Return to work

Prior to your return from a protected leave that is for a medical reason, you will need to have your medical provider complete the Release to Return to Work Form HR 026, and return it to the Human Resource Department prior to your first day back.

Forms

  
  
  
HR 016Protected Leave Instructions59 KB
HR 017Protected Leave Application1241 KB
HR 018Release of Health Information1238 KB
HR 019Health Care Provider - Serious (Self)143 KB
HR 020Health Care Provider - Serious (Family)60 KB
HR 021Military Exigency Leave61 KB
HR 022Military Family Leave68 KB
HR 023Veteran Military Caregiving Leave120 KB
HR 026Release to Return to Work48 KB

Contact us

Human Resources Department
Monday–Friday
8:00 a.m.–5:00 p.m.
555 Liberty ST SE RM 225
Salem OR 97301
Phone: