Nalc Form 5 - Certification For Serious Injury Or Illness Of A Veteran For Military Caregiver Leave (Fmla)

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NALC Form 5 Family and Medical Leave Act Form
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 for Serious Injury or Illness* of a Veteran for Military Caregiver Leave (FMLA)
Section 1: For completion by the employee and/or the veteran for whom the employee is requesting leave.
A. Name (First, Middle, and Last) of the employee requesting leave to care for veteran:
_______________________________________________________________________________________________________
EIN: __________________________________________ FMLA Case # (if known): ____________________________________
B. Name (First, Middle, and Last) of veteran (for whom employee is requesting leave to care for):
_______________________________________________________________________________________________________
C. Relationship of veteran to employee:
Spouse
Parent
Son
Daughter
Next of Kin
D. Veteran Information
1) Date of the veteran’s discharge: ___________________________________________________________________________
2) Was the veteran dishonorably discharged or released from the Armed Forces (including the National Guard or Reserves)?
Yes
No
3) Please provide the veteran’s military branch, rank and unit at the time of discharge:
_______________________________________________________________________________________________________
4) Is the veteran receiving medical treatment, recuperation or therapy for an injury or illness?
Yes
No
E. Describe the care to be provided to the veteran and an estimate of the leave needed to provide the care:
_____________________________________________________________________________________
_____________________________________________________________________________________
*SERIOUS INJURY OR ILLNESS—A serious injury or illness means an injury or illness incurred by the servicemember in the line
of duty on active duty in the Armed Forces (or that existed before the beginning of the servicemember’s active duty and was
aggravated by service in the line of duty on active duty in the Armed Forces) and manifested itself before or after the servicemem-
ber became a veteran, and is:
(i) a continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member of the Armed
Forces and rendered the servicemember unable to perform the duties of the servicemember’s office, grade, rank, or rating; or
(ii) a physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs Service
Related Disability Rating (VASRD) of 50 percent or greater, and such VASRD rating is based, in whole or in part, on the condition
precipitating the need for military caregiver leave; or
(iii) a physical or mental condition that substantially impairs the covered veteran’s ability to secure or follow a substantially gainful
occupation by reason of a disability or disabilities related to military service, or would do so absent treatment; or
(iv) an injury, including a psychological injury, on the basis of which the covered veteran has been enrolled in the Department of
Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
NALC Form 5 (page 1 of 2) - 5/24/2013

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