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Certification Of Qualifying Exigency For Military Family Leave WH-384 - Official Federal Forms
| Certification Of Qualifying Exigency For Military Family Leave Form. This is a national form and can be used in US Dept Of Labor . |
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Certification of Qualifying Exigency For Military Family Leave (Family and Medical Leave Act) U.S. Department of Labor Wage and Hour Division OMB Control Number: 1235-0003 Expires: 2/28/2015 SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a qualifying exigency to submit a certification. Please complete Section I before giving this form to your employee. Your response is voluntary, and while you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.309. Employer name: _______________________________________________________________________________ Contact Information: ___________________________________________________________________________ SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II fully and completely. The FMLA permits an employer to require that you submit a timely, complete, and sufficient 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 a benefit. 29 C.F.R. § 825.310. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at least 15 calendar days to return this form to your employer. Your Name: __________________________________________________________________________________ First Middle Last Name of covered military member on active duty or call to active duty status in support of a contingency operation: ____________________________________________________________________________________________ First Middle Last Relationship of covered military member to you: _____________________________________________________ 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 includes 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 employer with sufficient written documentation confirming the covered military member's active duty or call to active duty status in support of a contingency operation. Page 1 CONTINUED ON NEXT PAGE Form WH-384 January 2009 American LegalNet, Inc. www.FormsWorkFlow.com PART A: QUALIFYING REASON FOR LEAVE 1. Describe the reason you are requesting FMLA leave due to a qualifying exigency (including 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 briefings 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. __ Yes __ No __ None Available PART B: AMOUNT OF LEAVE NEEDED 1. Approximate date exigency commenced: _____________________________________________________ Probable duration of exigency: _____________________________________________________________ 2. Will you need to be absent from work for a single continuous period of time due to the qualifying exigency? ___No ___Yes. If so, estimate the beginning and ending dates for the period of absence: _____________________________________________________________________________________. 3. Will you need to be absent from work periodically to address this qualifying exigency? ___No ___Yes. Estimate schedule of leave, including the dates of any scheduled meetings or appointments:__________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time (i.e., 1 deployment-related meeting every month lasting 4 hours): Frequency: _____ times per _____ week(s) _____ month(s) Duration: _____ hours ___ day(s) per event. Page 2 CONTINUED ON NEXT PAGE Form WH-384 January 2009 American LegalNet, Inc. www.FormsWorkFlow.com PART C: If leave is requested to meet with a third party (such as to arrange for childcare, to attend counseling, to attend meetings with school or childcare providers, to make financial or legal arrangements, to act as the covered military member's representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and sufficient certification includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either the telephone or fax number or email address of the indiv
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