Fillable FMLA Qualifying Exigency Military Family Form 3-9-16 (City University of New York)

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FMLA Qualifying Exigency Military Family Form 3-9-16 (City University of New York)

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The FMLA Qualifying Exigency Military Family Form 3-9-16 (City University of New York) form is 2 pages long and contains:

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FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE
OHRM - FMLA- CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE FORM - 2015. Page 1
Empl. ID
Department
Section 1: TO BE COMPLETED BY EMPLOYEE
Name of Employee
Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you are requesting leave):
Name of military member on covered active duty or call to covered active duty status
Period of military member's covered active duty
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation
confirming a military member's covered active duty or call to covered active duty status.
Please check one of the following and attach the indicated document to support that the military member is on covered active duty or call to
covered active duty status.
A copy of the military member's covered active duty orders is attached
Other documentation from the military certifying that the military member is on covered active duty (or has been notified of an impending
call to covered active duty) is attached.
I have previously provided sufficient written documentation confirming the military member's covered active duty or call to covered active
duty status.
PART A: QUALIFYING REASON FOR LEAVE
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 the military member's Rest and Recuperation Leave; a document confirming an
appointment with a third party, such as a counselor or school official, or staff at a care facility; or a copy of a bill of services for the handling of
legal or financial affairs.
Yes, attached
No, not attached
None available
Contract Title
Tel.:
This form must be returned by
The FMLA permits CUNY to require that you submit a timely, complete and sufficient certification to support a request for FMLA leave due to a
qualifying exigency. Questions below 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 the
benefit of FLMLA-protected leave. Failure to provide a complete and sufficient certification may result in denial of your FMLA leave request.
Attach the CERTIFICATION OF FAMILY RELATIONSHIP FORM and any other supporting documents, as necessary.
CUNY gives you at least 15 calendar days to return this form.
FMLA FORM-3 C
College
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE
PART B: AMOUNT OF LEAVE NEEDED
OHRM - FMLA- CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE FORM - 2015. Page 2
Approximate date exigency commenced
Probable duration of exigency
Yes
Will you need to be absent from work for a single continuous period of time due to the qualifying exigency?
No
From Date
To Date
Will you need to be absent from work periodically to address the qualifying exigency?
No
Yes
Describe the nature of the meeting:
If yes, estimate the beginning and ending dates for the period of absence:
To Date
From Date
If yes, estimate schedule of leave, including dates of any scheduled
meetings or appointments
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time (e.g., one deployment-related
meeting every month lasting 4 hours)
No. of day(s) per event
No. of hours
Duration
No. of times per month
No. of times per week
Frequency
PART C:
If leave is requested to meet with a third party (such as to arrange for childcare or parental care, to attend counseling, to attend meetings with
school, childcare or parental care providers, to make financial or legal arrangements, to act as the 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 e-mail address of the individual
or entity). CUNY may use this to verify that the information submitted on this form is accurate.
Name of Individual
Title
Organization
State
Zip Code
Address
City
State
Zip Code
Telephone
FAX
Email
PART D: CERTIFICATION BY EMPLOYEE
I certify that the information I provided is true and correct.
Date
Print Name
Signature
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FMLA Qualifying Exigency Military Family Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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