Fillable Certification of Qualifying Exigency U.S. Department of Labor (East Central College)

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Certification of Qualifying Exigency U.S. Department of Labor (East Central College)

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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 employ
ee 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 co
m
p
lete a
nd sufficient
certification to support a request
for FMLA leave due to a qualify
i
ng exigency includes
written documentation confirming a covered military member’s active dut
y 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 dut
y
orders is attach
ed.
___
Other documentation from the m
ilitary
certify
i
ng 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 dut
y or call to active duty status in support of a contingency operation.
Page 1 CONTINUED ON NEXT PAGE Form WH-384 January 2009
PART A: QUALIFYING REASON FOR LEAVE
1. Desc
ribe the reason y
o
u are requesting FMLA leave
due to a qualify
ing exigency (including the specific
reason you are requesting leave):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2. A co
m
p
lete and sufficient
certification to support a request for FMLA leave due to a qualify
ing 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 qualify
ing exigency? ___No ___Yes.
Estimate schedule of leave, including the dates of any scheduled meetings or
appointm
e
nts:____
___
___
________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Estimate the frequency and duration of each appointment, meeting, or leave event, includi
ng 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
PART C:
If leave is requested to meet with a third party (such as to arrange fo
r childcare, to attend couns
eling, to atten
d
meetings with school or c
hildcare 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
individual or entity). This information may be used by your employer to verify that the information contained on
this form is accurate.
Name of Individual: ___________________________ Title: ___________________________________________
Organization: _________________________________________________________________________________
Address: _____________________________________________________________________________________
Telephone: (
________)_________________________ Fax: (_______)____________________________________
Email: _______________________________________________________________________________________
Describe nature of meeting: _________
________
___
_
____
___
__________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PART D:
I certify that the information I provided above is true and correct.
___________________________________________ ________________________________________
Signature of Employee
Date
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years.
29 U.S.C. § 2616; 29
C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this
collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate
or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator,
Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, DC 20210. DO NOT
SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE EMPLOYER.
Page 3 Form WH-
384 January 2009
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Certification of Qualifying Exigency U.S. Department of Labor (East Central College)

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