Medical Certification Employees Own Serious Health Condition Form (Page 5 of 18) in pdf

NALC Form 3 - Family and Medical Leave Act

Employee: Return the completed form to the appropriate FMLA administration HRSSC address or fax (see attached sheet) and keep a copy for your own records.

Certification of Qualifying Exigency for Military Family Leave

1. Employee’s name (First, Middle, and Last): __________________________________________________________________

EIN: __________________________________________ FMLA Case # (if known): ____________________________________

2. Name of military member on covered active duty or call to covered active duty* (First, Middle, and Last):

_______________________________________________________________________________________________________

❒

3. Relationship of military member to employee:

Spouse

Parent

Son or Daughter

4. Dates of military member’s covered active duty: ___________________________________________

5. Documents confirming the military member’s covered active duty or call to covered active duty status. Please check one of

the following:

❒ A copy of the military member’s covered active duty orders is attached.

❒ Other documentation from the military is attached certifying that the military member is on covered active duty (or has been notified of an

impending call to covered active duty).

❒ I have previously provided my employer with sufficient written documentation confirming the military member’s covered active duty or call to

covered active duty.

6. Qualifying reason for leave. The back of this form describes how the Family Medical Leave Act defines “qualifying exigencies.”

Does the need for leave qualify under any of the exigencies described? If so, please check the appropriate exigency.

❒ 1 Short notice deployment ❒ 2 Military events and related activities

❒ 3 Childcare and school activities involving a child of the military member ❒ 4 Financial and legal arrangements ❒ 5 Counseling

❒ 6 Rest and recuperation ❒ 7 Post-deployment activities ❒ 8 Parental care involving a parent of a military member ❒ 9 Additional activities

Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you are requesting leave):

________________________________________________________________________________________________________

8. Documents supporting the request for leave for a qualifying exigency.

Please attach any available written documentation that supports the need for leave; such documentation may include a copy of a

meeting announcement for informational briefings sponsored by the military, a document confirming an appointment with a coun-

selor or school official, or a copy of a bill for services for the handling of legal or financial affairs. If leave is taken for rest and recu-

peration, a copy of the military member’s rest and recuperation orders must be submitted. Available written documentation is

❒

attached.

Yes

None Available

9. Amount of leave needed.

a. Approximate date the exigency commenced or will commence: _______________________________________________

❒

b. Will you need to be absent from work for a single continuous period of time due to the qualifying exigency?

Yes

If yes, estimate the beginning and ending dates for the period of absence: _______________________________________

❒

c. Will you need to be absent from work periodically to address this qualifying exigency?

Yes

If yes, estimate the frequency and duration of each period of absence due to the qualifying exigency (i.e. 1 deployment-related

meeting every month lasting 4 hours.)

Frequency

_____ time(s) per _____ week(s) _____ month(s)

Duration:

_____ hour(s) or _____ day(s) per event.

10. Leave to meet with a third party. Complete this section if leave is requested to meet with a third party (such as to arrange for

childcare, to attend counseling, to attend meetings with school or childcare providers, to make financial or legal arrangements, to

act as the military member’s representative before a federal, state or local agency for purposes of obtaining, arranging or appealing

military service benefits, or to attend any event sponsored by the military or military service organizations). The employer may use

this information to verify that the information on this form is accurate.

Name of Individual: _______________________________________________________Title: _____________________________

Organization: _____________________________________________________________________________________________

Address: ________________________________________________________________________________________________

Telephone: ________________________Fax: _________________________ Email: ____________________________________

Date of Meeting/Appointment: ___________________________

Briefly describe the nature of the meeting/appointment: ___________________________________________________________

_______________________________________________________________________________________________________

I certify that information I provided above is true and correct.

Signature of employee: _____________________________________________________Date:________________________

NALC Form 3 (page 1 of 2) - 5/24/2013

Medical Certification Employees Own Serious Health Condition Form Page 5

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