Designation Form (Family And Medical Leave Act) (Page 2 of 2) in pdf

Designation Form (Family And Medical Leave Act) Page 2

Additional information is needed to determine if your FMLA leave request can be approved:

The certification you have provided is not complete and sufficient to determine whether the FMLA applies to your leave request.

You must provide the following information no later than __________________ (provide at least seven calendar days), unless it

is not practicable under the particular circumstance despite your diligent good faith efforts, or your leave may be denied.

Information needed to make the certification complete and sufficient is:

____________________________________________________________________________________________________

We are exercising our right to have you obtain a second or third opinion medical certification at our expense, and we will

provide further details at a later time.

Your FMLA leave request is Not Approved.

The FMLA does not apply to your leave request.

You have exhausted your FMLA leave entitlement in the applicable 12 – month period.

Appointing Authority Signature and Comments:

__________________________________________________________________

__________________________________

(Signature of Appointing Authority or Designee)

(Date)

cc: Employee's Agency Confidential Medical File

Designation Form

NPD-63

Page 2 of 2

Rev. 3.13

Designation Form (Family And Medical Leave Act) Page 2