Certification of Qualifying Exigency for Military Family Leave(trk changes)

C ertification of Qualifying Exigency U.S. Department of Labor

For Military Family Leave Wage and Hour Division

(Family and Medical Leave Act)

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 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 covered active duty or call to covered 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 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 covered military member’s covered active duty or call to covered active duty status in support of a contingency operation. 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 covered military member’s covered active duty orders is attached.

¨ Other documentation from the military certifying that the covered military member is on covered active duty (or has been notified of an impending call to covered 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 covered active duty or call to covered active duty status in support of a contingency operation.

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 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 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?

Yes¨ No¨

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? Yes¨ No¨

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.

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, or childcare or parental care 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.