Request For Family/medical Leave Form - District Of Columbia Government Page 2
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2❑ Intermittently, in accordance with paragraph ___ of DPM Instruction No. 12-40.
Do you wish to continue your health benefits during the unpaid period of your family leave entitlement?
❑ Yes (I understand that I am responsible for continuing to pay my share of the health benefit premium.)
❑ No (Attach declination of benefits form). I understand that by canceling my health benefits enrollment I cannot re-
enroll in the health benefits program until the earlier of (1) the next health benefits “Open Season,” or (2) upon satisfying
a health benefits enrollment event.
4.
TO BE COMPLETED IF APPLYING FOR MEDICAL LEAVE
A. I hereby request
hours of medical leave because of a serious health condition.
B.
I am requesting the following type(s) of leave for medical leave. (I understand that I may elect to use my accrued sick leave
and, if agreed to by my agency, accrued annual leave, and/or compensatory time; and, in so using this leave, any sick leave,
annual leave, and/or compensatory time will count against my total 16-workweek entitlement to medical leave.)
❑ *Sick leave: Number of hours ______
❑ *Annual leave: Number of hours __________
❑ *Compensatory time: 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 file and attach form SF-71, “Application for Leave,” when requesting this type of leave.)
C.
The period of medical leave requested in Section 4A above is to be taken:
❑ In a continuous block of time from
to
.
❑ Intermittently as medically necessary.
Do you wish to continue your health benefits during the unpaid period of your medical leave entitlement?
❑ Yes (I understand that I am responsible for continuing to pay my share of the health benefit premium.)
❑ No (Attach declination of benefits form). I understand that by canceling my health benefits enrollment I cannot re-
enroll in the health benefits program until the earlier of (1) the next health benefits “Open Season,” or (2) upon
satisfying a health benefits enrollment event.
A medical certification of your “serious health condition,” issued by your health care provider, must be attached to this
application.
5.
EMPLOYEE CERTIFICATION
I certify that the above statements are true to the best of my knowledge and belief, and that I am eligible to participate in the
District of Columbia Family and Medical Leave Act of 1990.
Signature
Date
TO BE COMPLETED BY THE EMPLOYING AGENCY:
❑
❑
Approved
Disapproved
__________________________________
____________________________
(Signature of Approving Official)
Date
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