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NALC Form 4 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 Current Covered Servicemember for Military Caregiver Leave

Section 1: For completion by the employee and/or the covered servicemember for whom the employee is requesting leave.

A. Name (First, Middle, and Last) of the employee requesting leave to care for covered servicemember:

_______________________________________________________________________________________________________

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

B. Name (First, Middle, and Last) of covered sevicemember (for whom employee is requesting leave to care for):

_______________________________________________________________________________________________________

C. Relationship of covered servicemember to employee:

❒

Spouse

Parent

Son

Daughter

Next of Kin

D. Has an ITO (Invitational Travel Order) or ITA (Invitational Travel Authorization) been issued to a family member of the covered

❒

servicemember (the employee need not be the family member named)?

Yes

If yes, the period of time specified in the ITO or ITA: from ____________ to ____________

If the requested leave to care for the covered servicemember falls within the time period specified on the ITO or ITA, present a

copy of the ITO or ITA to the appropriate Postal Service Supervisor. No further certification is required. However, in order for the

employee to take military caregiver leave outside the period indicated on the ITO or ITA, the rest of this form must be completed.

E. Is the covered servicemember a current member of the Regular Armed Forces, the National Guard or Reserves?

❒

Yes

If yes, please provide the covered servicemember’s military branch, rank and unit currently assigned to:

___________________________________________________________________________________

F. Is the covered servicemember assigned to military medical treatment facility as an outpatient or to a unit established for the

purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients (such as a

❒

medical hold or warrior transition unit)?

Yes

No. If yes, please provide the name of the medical treatment facility or unit:

_____________________________________________________________________________________

❒

G. Is the covered servicemember on the Temporary Disability Retired List (TDRL)?

Yes

H. Describe the care to be provided to the covered servicemember and an estimate of the leave needed to provide the care:

_____________________________________________________________________________________

*SERIOUS INJURY OR ILLNESS.—The term ‘serious injury or illness’ means an injury or illness that was incurred by the covered

servicemember in the line of duty on active duty in the Armed Forces (or existed before the beginning of the covered servicemem-

ber’s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces) and that may render the

covered servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating.

NALC Form 4 (page 1 of 2) - 5/24/2013

Nalc Form 4 - Family And Medical Leave Act Form - Certification For Serious Injury Or Illness Of Current Covered Servicemember For Military Caregiver Leave

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