Uab Certification Of Qualifying Exigency For Military Family Leave (Fmla)

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Certification of Qualifying Exigency for Military Family Leave (FMLA)

For Completion by the Employee

Please complete fully and completely. FMLA permits an employer to require that you submit a timely, complete, and sufficient certification to support a

request for FMLA leave due to a qualifying exigency. The questions in this section require a response as to the frequency or duration of the qualifying

exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Your response is

required to obtain a benefit. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave.

You have 15 calendar days to return this form to UAB Human Resources at: 701 South 20

Street, AB 254 or via fax 205.996.9954

Full Name:____________________________________________________

Employee ID Number:________________________

Job Title: ___________________________ _________________________

Employee Phone Number: ____________________

Department: ___________________________________________________

Department Contact Number:__________________

Name of covered military member on active duty or call to active duty status in support of a contingency operation:

_________________________________________________________________________________________________________________________

Last Name

First Name

Relationship of covered military member to you: __________________________________________________________________________________

Period of covered military member’s active duty: _________________________________________________________________________________

You must provide complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency including written documentation

to confirm the military member’s active duty or call to active duty status in support of a contingency operation. Please check one of the following:

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

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

to active duty) in support of a contingency operation is attached.

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

duty status in support of a contingency operation

Part A. QUALIFYING REASON FOR LEAVE

1. Please check the applicable box below and then describe the reason for leave:

_______ Rest and recuperation – up to 5 days leave to spend time with military member during temporary, rest and recuperation

_______ Military events and related activities – official ceremonies, programs, or events sponsored by military related to active duty call

_______ Counseling activities – provided by someone other than health care provider for the employee, military member, or military member’s child

_______ Childcare and school activities – to make alternative childcare arrangements, enroll in or transfer military member’s child, or to attend

meetings at school or daycare

_______ Financial and legal arrangements

_______ Post-deployment activities – to attend arrival ceremonies, briefings or the official ceremonies or programs sponsored by the military and

events for a period of 90 days following termination of military member’s active status.

_______ Short notice deployment activities – up to 7 days leave if military member receives less than 7 days notice of impending call to active duty to

active duty

2. A complete and sufficient certification to support a request for FMLA leave due to qualifying exigency includes any available written documentation

which supports the need for leave; documentation may include a copy of a meeting announcement for the informational briefings sponsored by the

military, a copy of a bill for services for the handling of legal or financial affairs, document confirming appointment with school official or counselor, etc.

Available written documentation supporting this request for leave is attached.

__________Yes

__________No

__________None available

Revised 02/2011