Certification Of Qualifying Exigency For Military Family Leave Form printable pdf download

Certification of Qualifying Exigency for Military Family Leave Form

(UNMH Policy 175 – Family and Medical Leave)

Section I. For Completion by the EMPLOYEE.

INSTRUCTIONS TO EMPLOYEE: Please complete Section I fully and completely. UNMH requires

that you submit a timely, complete, and sufficient medical certification to support a request for FMLA

leave due to a qualifying exigency. Several questions in this section seek 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 benefits. While you are not required to provide this information, failure to do so may result in a

denial of your request for FMLA leave.

Employee Name:______________________________________________________________________

Name of covered military member: ________________________________________________________

Relationship to you of the covered military member: __________________________________________

Period of covered military member’s active duty: _____________________________________________

A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency

included written documentation confirming a covered 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 supervisor with sufficient written documentation confirming the

covered military member’s active duty or call to active duty status in support of a contingency

operation.

PART A. QUALFYING REASON FOR LEAVE

1. Describe the reason you are requesting FMLA leave due to a qualifying exigency (include the specific

reason you are requesting leave):

________________________________________________________________________________

2. A complete and sufficient certification to support a request for FMLA leave due to a qualifying

exigency includes any available written documentation which supports the need for leave; such

documentation may include a copy of a meeting announcement for informational briefing sponsored

by the military, a document confirming an appointment with a counselor or school official, or a copy of

a bill for services for the handling of legal or financial affairs. Available written documentation

supporting this request for leave is attached: No Yes  Not Available

PART B. AMOUNT OF LEAVE NEEDED

1. Approximate date exigency commenced: _______________________________________________

Probable duration of exigency: ________________________________________________________

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Certification Of Qualifying Exigency For Military Family Leave Form