DISTRICT OF COLUMBIA GOVERNMENT
REQUEST FOR FAMILY/MEDICAL LEAVE
[District of Columbia Family and Medical Leave Act of 1990]
TO BE COMPLETED BY THE EMPLOYEE
1.
IDENTIFICATION INFORMATION
Name: _________________________________________________________________________________________
(Last)
(First)
(Middle)
Last 4 Digits of Social Security Number: _______________________________________________________________
Position Title/Series/Grade: _________________________________________________________________________
Department or Agency: _____________________________________________________________________________
Organization Code: ________________________________________________________________________________
2.
CATEGORY OF LEAVE REQUESTED
I hereby make application for leave under the authority of the District of Columbia Family and Medical Leave Act of 1990 (D.C.
Law 8-181; D.C. Official Code § 32-501 et seq.), Chapter 16 of Title 4, District of Columbia Municipal Regulations, and DPM
Instruction No. 12-40.
(Check One): ❑ Family Leave
❑ Medical Leave
3.
TO BE COMPLETED IF APPLYING FOR FAMILY LEAVE
A. I hereby request
hours of family leave for one of the following purposes:
❑ The birth of my child
❑ The placement of a child with me for adoption or foster care
❑ The placement of a child with me for whom I will discharge and assume parental responsibility
❑ To provide care for a family member who has a serious health condition
B.
I am requesting the following type(s) of leave for family leave. (I understand that I may elect to use my accrued annual
leave, and/or compensatory time for family leave and, in so using this leave, any annual leave, and/or compensatory time
will count against my total 16-workweek entitlement to family leave.)
(Check appropriate box(es))
❑ *Annual leave: Number of hours ______
❑ *Compensatory time off: Number of hours ______
❑ Exempt Time Off: Number of hours _______
❑ Leave bank hours: Number of hours ______
❑ Leave without pay: Number of hours ______
❑ Voluntary Leave Transferred: Number of hours ______
TOTAL NUMBER OF HOURS ____________
* (You must complete and attach form SF-71, “Application for Leave,” when requesting this type of leave.)
If this application is to provide care for a family member, a medical certification of the “serious health condition,” issued by
your family member’s health care provider, must be attached to this application.
C.
The period of family leave requested in Section 3A above is to be taken:
❑ In a continuous block of time from
to
.
❑ On a reduced leave schedule as mutually agreed to by my agency from
to
. I understand that the 16 weeks of family leave on a reduced leave schedule must be taken within a
period that does not exceed 24 consecutive workweeks.