Department of Employee Relations
r. 4.01.2020
EMERGENCY FMLA DESIGNATION NOTICE
1. Your Request for Emergency FMLA Leave for care of a child whose school or childcare has been affected by
COVID-19 is approved beginning:
This time may be taken intermittently as needed; however you will need to discuss scheduling of your leave with your
supervisor ahead of time. You will be required to follow all departmental call-in procedures if an unforeseen need for leave
occurs. Leave taken will be counted against your total federal FMLA entitlement, if applicable.
2. Your Request for EFMLA is not approved because:
You have not met the EFMLA service requirement (30 days).
You have exhausted your FMLA leave entitlement in the applicable 12-month period.
Your request for leave is not covered by the Federal EFMLA
Other:
3. Your request for FMLA leave is pending until additional information is received.
Documentation of qualifying family relationship.
Documentation of school or childcare closure on unavailability
Please provide the information requested below no later than (at least 7 calendar days) unless it is not
practicable under the particular circumstances. Failure to provide information by the due date may result in FMLA
denial.
Approving Officer’s Signature (leave administrator)
Approving Officer’s Title
Approving Officers’ name (printed):
Departmental FMLA Administrator:
Departmental FMLA Administrator is responsible completing this form and for providing a copy of this completed form to
employee’s supervisor, employee’s payroll clerk, and the DER Leave Administration Coordinator.
☐ Copy to Department of Employee Relations
☐ Copy to Departmental Payroll
☐ Original to confidential Medical File
