Form CALHR756 "Certification of Qualifying Exigency Leave for Military Family Leave" - California

What Is Form CALHR756?

This is a legal form that was released by the California Department of Human Resources - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2021;
  • The latest edition provided by the California Department of Human Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CALHR756 by clicking the link below or browse more documents and templates provided by the California Department of Human Resources.

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Download Form CALHR756 "Certification of Qualifying Exigency Leave for Military Family Leave" - California

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Certification of Qualifying Exigency Leave
for Military Family Leave
California Department of Human Resources
State of California
Print Form
Reset Form
QUALIFYING EXIGENCY LEAVE
Part A. For Completion by the Employee
INSTRUCTIONS to EMPLOYEE: The FMLA permits that you submit a timely, complete, and sufficient
certification to support a request for FMLA leave due to a qualifying exigency or deployment to a foreign
country. Several questions in this section seek a response as to the frequency or duration of the
deployment. 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. While you are not
required to provide this information, failure to do so may result in a denial of your request for FMLA
leave. You have 15 calendar days to return this form.
Employee Last Name
Date
Employee First Name
Employee Middle Name
Division/Unit
Daytime Telephone Number
Name of the covered military member on active duty or call to active duty status:
Last Name
First Name
Middle Name
Your relationship to the covered service member:
Spouse
Parent
Child
Period of military member's active duty:
A complete and sufficient certification to support a request for FMLA leave due to active duty or call to
active duty status includes written documentation confirming a covered military member's active duty or
call to active duty status in support of a contingency operation or deployment to a foreign country.
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) 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.
Part B. Qualifying Reason for Leave
1. Describe the specific reason you are requesting FMLA leave due to a qualifying exigency or
deployment to a foreign country (attach a separate sheet of paper if additional space is needed):
2. A complete and sufficient certification to support a request for FMLA leave 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
CalHR 756
(rev 08/2021)
Page 1 of 3
Certification of Qualifying Exigency Leave
for Military Family Leave
California Department of Human Resources
State of California
Print Form
Reset Form
QUALIFYING EXIGENCY LEAVE
Part A. For Completion by the Employee
INSTRUCTIONS to EMPLOYEE: The FMLA permits that you submit a timely, complete, and sufficient
certification to support a request for FMLA leave due to a qualifying exigency or deployment to a foreign
country. Several questions in this section seek a response as to the frequency or duration of the
deployment. 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. While you are not
required to provide this information, failure to do so may result in a denial of your request for FMLA
leave. You have 15 calendar days to return this form.
Employee Last Name
Date
Employee First Name
Employee Middle Name
Division/Unit
Daytime Telephone Number
Name of the covered military member on active duty or call to active duty status:
Last Name
First Name
Middle Name
Your relationship to the covered service member:
Spouse
Parent
Child
Period of military member's active duty:
A complete and sufficient certification to support a request for FMLA leave due to active duty or call to
active duty status includes written documentation confirming a covered military member's active duty or
call to active duty status in support of a contingency operation or deployment to a foreign country.
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) 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.
Part B. Qualifying Reason for Leave
1. Describe the specific reason you are requesting FMLA leave due to a qualifying exigency or
deployment to a foreign country (attach a separate sheet of paper if additional space is needed):
2. A complete and sufficient certification to support a request for FMLA leave 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
CalHR 756
(rev 08/2021)
Page 1 of 3
Part C. Amount of Leave Needed
1. Approximate date exigency or deployment to a foreign country commenced:
2. Probable duration of deployment:
3. Will you need to be absent from work for a single continuous period of time due to the deployment?
Yes
No
If Yes, estimate the beginning and ending dates for the period of absence:
to
4. Will you need to be absent from work periodically to address the deployment?
Yes
No
If Yes, estimate schedule of leave, including the dates of any scheduled meetings or appointments:
5. Estimate the frequency and duration of each appointment, meeting, or leave event, including any
travel time (e.g., 1 deployment-related meeting every month lasting 4 hours):
times per
week(s)
month(s)
Frequency:
hours
day(s) per event
Duration:
Part D. Third Party Information
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 (e.g.,
either the telephone or fax number or e-mail address of the individual or entity). This information may be
used to verify the accuracy of the information contained on this form.
Name of Individual
Title
Organization
Email
Address
City
State
Zip Code
Telephone
Fax
Describe Nature of Meeting
Part E. Employee Certification
I certify that the information I provided is true and correct.
Signature of Employee
Date
CalHR 756
(rev 08/2021)
Page 2 of 3
Privacy Notice
This notice is provided pursuant to the Information Practices Act of 1977.
The California Department of Human Resources (CalHR), Personnel Management Division is
requesting the information specified on this form.
The information collected will be used for purposes of determining your eligibility for FMLA/CFRA,
benefits.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide
the information requested, there may be a delay in processing your request.
Department Privacy Policy
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977
and state policy. For more information on how we care for your personal information, please read our
Privacy Policy on CalHR's website (calhr.ca.gov).
Access to Your Information
Information provided on this form will be maintained by the CalHR Personnel Management Division
pursuant to State Administrative Manual retention requirements. Individuals have the right of access to
copies of this form on request. Send requests to:
Personnel Management Division
Department of Human Resources
1515 S Street, Suite 500N
Sacramento, CA 95811
CalHR 756
(rev 08/2021)
Page 3 of 3
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