IMPORTANT NOTICE
REGARDING YOUR REQUEST
FOR MILITARY FAMILY LEAVE
(COVERED SERVICEMEMBER)
Southern West Virginia Community and Technical College
NAME: Date:
This will serve as official notification that this period of medical leave counts
toward entitlement of Military Family Leave under the Family and Medical Leave
Act (FMLA), which provides up to 26 weeks job-protected leave during a single 12-
month period for eligible employees to care for a covered servicemember who has
a serious injury or illness incurred in the line of duty on active duty.
SCP-2006 Employee Leave policy requires employees who have been absent
longer than two consecutive work weeks, due to medical reasons for themselves or a
family member, complete a request for medical leave and the supporting
physician’s statement. Failure to comply with policy may result in the employee
being removed from the payroll.
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
RETURN TO WORK AUTHORIZATION
MEDICAL RELEASE FORM
PHYSICIAN - COMPLETE IN ENTIRETY:
Patient’s Name:
I hereby certify that the above-named employee has been under my professional care for:
(Diagnosis)
Illness commenced:
(Date)
Employee is able to return to work on:
(Date)
Describe the functional limitations/restrictions, if any, caused by this condition:
(Functional limitations listed may require an analysis of employee’s Position Information Questionnaire (PIQ) for ADA
accommodation)
Duration of limitations/restrictions, if any:
Permanent Temporary
If temporary, indicate time period:
Signature of Physician
Printed Name
Address of Physician
Telephone Number of Physician
Revised 3/16/2010
Certification for Serious Injury or
Illness of Covered Servicemember - -
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
Notice to 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 serious injury or illness
of a covered servicemember to submit a certification providing sufficient facts to support the request for leave.
Your response is voluntary. 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. § 825.310. Employers must generally
maintain records and documents relating to medical certifications, recertifications, or medical histories of
employees or employees’ family members, created for FMLA purposes as confidential medical records in separate
files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with
Disabilities Act applies.
SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom
the Employee Is Requesting Leave INSTRUCTIONS to the EMPLOYEE or COVERED
SERVICEMEMBER: Please complete Section I before having Section II completed. The FMLA permits an
employer to require that an employee submit a timely, complete, and sufficient certification to support a request for
FMLA leave due to a serious injury or illness of a covered servicemember. If requested by the employer, your
response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. §§ 2613, 2614(c)(3).
Failure to do so may result in a denial of an employee’s FMLA request. 29 C.F.R. § 825.310(f). The employer
must give an employee at least 15 calendar days to return this form to the employer.
SECTION II: For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH
CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of
Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care
provider; or (3) a DOD non-network TRICARE authorized private health care provider INSTRUCTIONS
to the HEALTH CARE PROVIDER: The employee listed on Page 2 has requested leave under the FMLA to
care for a family member who is a member of the Regular Armed Forces, the National Guard, or the 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. For purposes of FMLA leave, a serious injury or
illness is one that was incurred in the line of duty on active duty that may render the servicemember medically unfit
to perform the duties of his or her office, grade, rank, or rating.
A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember’s
serious injury or illness includes written documentation confirming that the covered servicemember’s injury or
illness was incurred in the line of duty on active duty and that the covered servicemember is undergoing treatment
for such injury or illness by a health care provider listed above. Answer, fully and completely, all applicable parts.
Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer
should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be
as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine
FMLA coverage. Limit your responses to the condition for which the employee is seeking leave.
Page 1 CONTINUED ON NEXT PAGE Form WH-385 January 2009
Certification for Serious Injury or Illness
of Covered Servicemember - - for
Military Family Leave (Family and
Medical Leave Act)
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom
the Employee Is Requesting Leave: (This section must be completed first before any of the below sections can be
completed by a health care provider.)
Part A: EMPLOYEE INFORMATION
Name and Address of Employer (this is the employer of the employee requesting leave to care for covered
servicemember):
____________________________________________________________________________________________
Name of Employee Requesting Leave to Care for Covered Servicemember:
____________________________________________________________________________________________
First Middle Last
Name of Covered Servicemember (for whom employee is requesting leave to care):
____________________________________________________________________________________________
First Middle Last
Relationship of Employee to Covered Servicemember Requesting Leave to Care:
Spouse Parent Son Daughter Next of Kin
Part B: COVERED SERVICEMEMBER INFORMATION
(1) Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or
Reserves? ___Yes ____No
If yes, please provide the covered servicemember’s military branch, rank and unit currently assigned to:
_______________________________________________________________________________________
Is the covered servicemember assigned to a military medical treatment facility as an outpatient or to a unit
established for the purpose of providing command and control of members of the Armed Forces receiving
medical care as outpatients (such as a medical hold or warrior transition unit)? ___
Yes ___No If yes, please
provide the name of the medical treatment facility or unit:
_________________________________________
(2) Is the Covered Servicemember on the Temporary Disability Retired List (TDRL)? ____Yes ____No
Part C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER
Describe the Care to Be Provided to the Covered Servicemember and an Estimate of the Leave Needed to Provide
the Care:
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 2 CONTINUED ON NEXT PAGE Form WH-385 January 2009
Southern WV Community & Technical College, P.O. Box 2900, Mount Gay, WV 25637 Telephone: (304) 896-7416
SECTION II: For Completion by a United States Department of Defense (“DOD”) Health Care Provider or
a Health Care Provider who is either: (1) a United States Department of Veterans Affairs (“VA”) health
care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-
network TRICARE authorized private health care provider. If you are unable to make certain of the
military-related determinations contained below in Part B, you are permitted to rely upon determinations
from an authorized DOD representative (such as a DOD recovery care coordinator). (Please ensure that
Section I above has been completed before completing this section.) Please be sure to sign the form on the last
page.
Part A: HEALTH CARE PROVIDER INFORMATION
Health Care Provider’s Name and Business Address:
____________________________________________________________________________________________
Type of Practice/Medical Specialty: _______________________________________________________________
Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD
TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized
private health care provider: _____________________________________________________________________
Telephone: ( ) _____________ Fax: ( ) ______________ Email: ___________________________________
PART B: MEDICAL STATUS
(1) Covered Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):
(VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently
endangered. Family members are requested at bedside immediately. (Please note this is an internal DOD
casualty assistance designation used by DOD healthcare providers.)
(SI) Seriously Ill/Injured – Illness/injury is of such severity that there is cause for immediate concern,
but there is no imminent danger to life. Family members are requested at bedside. (Please note this is an
internal DOD casualty assistance designation used by DOD healthcare providers.)
OTHER Ill/Injured – a serious injury or illness that may render the servicemember medically unfit to
perform the duties of the member’s office, grade, rank, or rating.
NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take
leave to care for a covered family member with a “serious health condition” under § 825.113 of the FMLA.
If such leave is requested, you may be required to complete DOL FORM WH-380 or an employer-provided
form seeking the same information.)
(2) Was the condition for which the Covered Service member is being treated incurred in line of duty on active
duty in the armed forces? ____ Yes
____ No
(3) Approximate date condition commenced: _______________________________________________
(4) Probable duration of condition and/or need for care: ______________________________________
(5) Is the covered servicemember undergoing medical treatment, recuperation, or therapy? ____Yes ___No. If
yes, please describe medical treatment, recuperation or therapy:
_________________________________________________________________________________________
Page 3 CONTINUED ON NEXT PAGE Form WH-385 January 2009
PART C: COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1) Will the covered servicemember need care for a single continuous period of time, including any time for
treatment and recovery? ___ Yes ___ No
If yes, estimate the beginning and ending dates for this period of time: ________________________________
(2) Will the covered servicemember require periodic follow-up treatment appointments?
___ Yes ___ No If yes, estimate the treatment schedule: __________________________________________
(3) Is there a medical necessity for the covered servicemember to have periodic care for these follow-up treatment
appointments? ____Yes _____No
(4) Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled
follow-up treatment appointments (e.g., episodic flare-ups of medical condition)? ____Yes ____No If yes,
please estimate the frequency and duration of the periodic care:
_________________________________________________________________________________________
_________________________________________________________________________________________
Signature of Health Care Provider: ________________________________ 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, in accordance with 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 PATIENT.
Page 4 Form WH-385 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