IMPORTANT NOTICE TO
FACULTY REQUESTING
MILITARY FAMILY LEAVE
(QUALIFYING EXIGENCY)
Southern West Virginia Community and Technical College
NAME: Date:
This notice will serve as a reminder that faculty employees who are unable to work
for a period of thirty (30) calendar days will be taken off the institution’s
payroll at the end of the 30-day period (See SCP-2006 § 6.5.4).
This period of medical leave counts toward entitlement of Military Family Leave
under the Family and Medical Leave Act (FMLA), which provides up to 12 weeks
job-protected leave for eligible employees with a family member on active duty or
call to active duty status in the National Guard or Reserves in support of a
contingency operation to address certain qualifying exigencies.
Certain qualifying exigencies may include attending certain military events,
arranging for alternative childcare, addressing certain financial and legal
arrangements, attending certain counseling sessions, and attending post-
deployment reintegration briefings.
Leave due to qualifying exigencies may be taken on an intermittent basis.
Please refer to SCP-2006 for additional information regarding Employee Leave.
Contact Human Resources:
Doug Kennedy
304.896.7408 or doug.kennedy@southernwv.edu
or
Susan Ross
304.896.7445 or susan.ross@southernwv.edu
REQUEST FOR
MEDICAL LEAVE OF ABSENCE
OR
MILITARY FAMILY LEAVE
Name: Employee ID No:
Title: Dept: _____
I hereby request a leave of absence as follows:
Beginning Date: ___
Ending Date: ___
Purpose of Leave:
The birth of a child, or placement of a child with you for adoption or foster care
Your own serious health condition
You are needed to care for your spouse, child, or parent due to his/her serious health condition
Qualifying exigency arising out of the fact that your spouse, son or daughter, or parent is on active duty or call to
active duty status in support of a contingency operation as a member of the National Guard or Reserves
You are the spouse, son or daughter, parent, or next of kin of a covered servicemember with a serious injury or illness
I understand that while on an approved Leave of Absence, I am required to continue to pay my respective proportionate share of
health/life/hospitalization/drug insurance coverage premium cost. I further understand that if the approved leave continues after 12
consecutive months, I may be required to pay the full cost of coverage (employee and employer’s share).
I further understand that prior to my return to work, I am required to submit to my employer the Return to Work Authorization
/Medical Release form from the treating licensed physician (except in the case of Military Family Leave due to qualifying exigency).
I further understand that the extent of this leave will count toward entitlement of the Family and Medical Leave Act (FMLA), which
provides up to 12 weeks job-protected leave to eligible employees for certain family and medical reasons and up to 26 weeks job-
protected leave to eligible employees to care for a covered servicemember under the Military Family Leave entitlement. See the
attached publication by the U.S. Department of Labor entitled “Employee Rights and Responsibilities Under the Family and Medical
Leave Act” (WHD Publication 1420).
I further understand that any extension of this leave must be requested in writing by completing a new Request for Medical Leave
of Absence or Military Family Leave and provide a new Certification, and be submitted for the President’s approval prior to the
expiration of this approved leave.
I understand that approval of this Request does not guarantee payment of wages, leave or other compensation and that
all policies, rules, and laws in regard to leave payment apply.
**IMPORTANT**
This request form MUST be accompanied by either a Certification of Health Care Provider (DOL Form WH-380-E or WH-380-F),
Certification of Qualifying Exigency (DOL Form WH-384), or a
Certification for Serious Injury or Illness of Covered Servicemember (Form WH-385)
Employee’s Signature Date
I recommend approval of this leave __Yes __No
Supervisor’s Signature Date
I recommend approval of this leave __Yes __No
Unit Administrator’s Signature Date
I recommend approval of this leave __Yes __No
Human Resources Administrator’s Signature Date
Approved Denied
Revised 3/16/2010 President or Designee’s Signature Date
RESERVED
RESERVED
FOR
FOR
HUMAN
HUMAN
RESOURCES
RESOURCES
DEPARTMENT
DEPARTMENT
USE
USE
ONLY
ONLY
DO NOT WRITE IN THIS BOX
I. Date leave commenced _____________ Expected end date _____________
II. Non-Faculty Employees Only:
1. Verification of Leave Balances as of _______________________ (Date)
Annual Leave _________ days
Sick Leave _________ days
2. Exhaustion of all sick/annual leave as of _______________________
(Date & Time)
3. Date Catastrophic Leave Request Form Sent ____________________________
(30 days prior to expiration of leave)
4. Applied for Catastrophic Leave? YES NO N/A
III. Date notification letter sent: _________________
IV. Verification of receipt of monthly physician’s statement:
Month
Date Rec’d in HR Month Date Rec’d in HR
(List below) (List Below)
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
V. Verification of receipt of monthly insurance premiums:
Month
Date Rec’d in HR Month Date Rec’d in HR
(List below) (List Below)
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
_______ _____________ _______ ____________
VI. Date of Actual Return to Work/Duty: _________________________
OR
Date extension of leave requested: __________________________
Certification of Qualifying Exigency
For Military Family Leave
(Family and Medical Leave Act)
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
OMB Control Number: 1215-0181
Expires: 12/31/2011
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
Southern WV Community & Technical College
P.O. Box 2900, Mount Gay, WV 25637 (304) 896-7416
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
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
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
EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
FMLA requires covered employers to provide up to 12 weeks of unpaid,
job-protected leave to eligible employees for the following reasons:
• for incapacity due to pregnancy, prenatal medical care or child birth;
• to care for the employee’s child after birth, or placement for adoption
or foster care;
• to care for the employee’s spouse, son, daughter or parent, who has
a serious health condition; or
• for a serious health condition that makes the employee unable to
perform the employee’s job.
Military Family Leave Entitlements
Eligible employees whose spouse, son, daughter or parent is on covered
active duty or call to covered active duty status may use their 12-week
leave entitlement to address certain qualifying exigencies. Qualifying
exigencies may include attending certain military events, arranging for
alternative childcare, addressing certain nancial and legal arrangements,
attending certain counseling sessions, and attending post-deployment
reintegration briengs.
FMLA also includes a special leave entitlement that permits eligible
employees to take up to 26 weeks of leave to care for a covered service-
member during a single 12-month period. A covered servicemember is:
(1) a current member of the Armed Forces, including a member of the
National Guard or Reserves, who is undergoing medical treatment,
recuperation or therapy, is otherwise in outpatient status, or is otherwise
on the temporary disability retired list, for a serious injury or illness*;
or (2) a veteran who was discharged or released under conditions other
than dishonorable at any time during the ve-year period prior to the
rst date the eligible employee takes FMLA leave to care for the covered
veteran, and who is undergoing medical treatment, recuperation, or
therapy for a serious injury or illness.*
*The FMLA denitions of “serious injury or illness” for
current servicemembers and veterans are distinct from
the FMLA definition of “serious health condition”.
Benets and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the
employee had continued to work. Upon return from FMLA leave, most
employees must be restored to their original or equivalent positions
with equivalent pay, benets, and other employment terms.
Use of FMLA leave cannot result in the loss of any employment benet
that accrued prior to the start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at
least 12 months, have 1,250 hours of service in the previous 12 months*,
and if at least 50 employees are employed by the employer within 75 miles.
*Special hours of service eligibility requirements apply to
airline ight crew employees.
Denition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical
or mental condition that involves either an overnight stay in a medical
care facility, or continuing treatment by a health care provider for a
condition that either prevents the employee from performing the functions
of the employee’s job, or prevents the qualied family member from
participating in school or other daily activities.
Subject to certain conditions, the continuing treatment requirement may
be met by a period of incapacity of more than 3 consecutive calendar days
combined with at least two visits to a health care provider or one visit and
a regimen of continuing treatment, or incapacity due to pregnancy, or
incapacity due to a chronic condition. Other conditions may meet the
denition of continuing treatment.
Use of Leave
An employee does not need to use this leave entitlement in one block.
Leave can be taken intermittently or on a reduced leave schedule when
medically necessary. Employees must make reasonable efforts to schedule
leave for planned medical treatment so as not to unduly disrupt the
employers operations. Leave due to qualifying exigencies may also be
taken on an intermittent basis.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid
leave while taking FMLA leave. In order to use paid leave for FMLA
leave, employees must comply with the employers normal paid leave
policies.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take
FMLA leave when the need is foreseeable. When 30 days notice is not
possible, the employee must provide notice as soon as practicable and
generally must comply with an employers normal call-in procedures.
Employees must provide sufcient information for the employer to determine
if the leave may qualify for FMLA protection and the anticipated timing
and duration of the leave. Sufcient information may include that the
employee is unable to perform job functions, the family member is unable
to perform daily activities, the need for hospitalization or continuing
treatment by a health care provider, or circumstances supporting the need
for military family leave. Employees also must inform the employer if
the requested leave is for a reason for which FMLA leave was previously
taken or certied. Employees also may be required to provide a certication
and periodic recertication supporting the need for leave.
Employer Responsibilities
Covered employers must inform employees requesting leave whether
they are eligible under FMLA. If they are, the notice must specify any
additional information required as well as the employees’ rights and
responsibilities. If they are not eligible, the employer must provide a
reason for the ineligibility.
Covered employers must inform employees if leave will be designated
as FMLA-protected and the amount of leave counted against the employee’s
leave entitlement. If the employer determines that the leave is not
FMLA-protected, the employer must notify the employee.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
interfere with, restrain, or deny the exercise of any right provided
under FMLA; and
• discharge or discriminate against any person for opposing any practice
made unlawful by FMLA or for involvement in any proceeding under
or relating to FMLA.
Enforcement
An employee may le a complaint with the U.S. Department of Labor
or may bring a private lawsuit against an employer.
FMLA does not affect any Federal or State law prohibiting discrimination,
or supersede any State or local law or collective bargaining agreement
which provides greater family or medical leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA
covered employers to post the text of this notice. Regulation
29 C.F.R. § 825.300(a) may require additional disclosures.
For additional information:
1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627
WWW.WAGEHOUR.DOL.GOV
U.S. Department of Labor Wage and Hour Division
WHD Publication 1420 · Revised February 2013