Form NIH2940 "Leave Recipient Application for the Nih Leave Bank"

What Is Form NIH2940?

This is a legal form that was released by the U.S. Department of Health and Human Services - National Institutes of Health on November 1, 2013 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2013;
  • The latest available edition released by the U.S. Department of Health and Human Services - National Institutes of Health;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form NIH2940 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - National Institutes of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form NIH2940 "Leave Recipient Application for the Nih Leave Bank"

1453 times
Rate (4.6 / 5) 102 votes
NIH LEAVE BANK RECIPIENT APPLICATION PACKAGE
Leave Recipient Application for the NIH Leave Bank – Instructions
This form is used to apply to become a Leave Recipient under the NIH Voluntary Leave Bank Program (Leave Bank). All
Leave Recipients are subject to all leave provisions outlined in 5 C.F.R. Part 630, Subpart J and NIH Leave Bank Policies
and Procedures. This instructions page is not all inclusive, so applicants must also read the NIH Leave Bank Policies and
Procedures, available at http://hr.od.nih.gov/benefits/leave/vlbp/resources.htm. All applicants and Leave Approving
Officials (LAOs) are encouraged to contact the NIH Leave Bank Office with any questions or concerns at 301-443-8393
or leavebank@od.nih.gov.
A complete Leave Recipient Application Package must be submitted to the Leave Bank Office no later than 30 calendar
days following the termination of the medical emergency. The package must include:
NIH 2941, NIH Leave Bank Cover Sheet
NIH 2940, The Recipient Application for the NIH Leave Bank
NIH 2923, Authorization for Disclosure of Information
Primary Medical Documentation (see NIH 2923 instructions page)
APPLICANT INFORMATION
To initiate the Leave Recipient process, the applicant shall complete NIH 2940, Section A, and submit the NIH 2940
along with this instructions page to his/her Leave Approving Official (LAO). If the Leave Recipient Applicant is unable to
complete the NIH 2940, a personal representative may complete the forms on his/her behalf.
A.1 – Applicant Information
A.2 – Leave Bank Request Information
For cases with an unknown start date (i.e. transplant), provide the recovery duration (i.e. 8 weeks) instead of the end date.
For intermittent needs, indicate the number of hours per week, per month, or per year required by the medical emergency.
A.3 – FMLA Request Information
Medical need is determined through the NIH Leave Bank verification process.
LEAVE APPROVING OFFICIAL INSTRUCTIONS
The LAO shall complete all items in NIH 2940, Section B and return to the Leave Recipient Applicant within five
business days of receipt. The LAO does not need to know the medical emergency. All cases will be sent for medical
review.
The LAO should indicate how much time out of the office the organization can support by selecting the
appropriate box (yes, some, FMLA Only, or no). If the LAO plans to disapprove the employee’s possible absence from
duty, the LAO should contact his/her servicing Employee Relations Specialist to discuss leave policies. To find the
appropriate Employee Relations Specialist, visit
http://intrahr.od.nih.gov/policyguidance/er/contacts.htm
(NIH- only).
If an applicant invokes the Family and Medical Leave Act of 1993 (FMLA), the LAO must approve the application
unless he/she has reason to believe that the employee is not eligible for FMLA. Leave Bank Members do not have an
entitlement to use leave granted by the Leave Bank Board unless the employee is eligible for an invoked FMLA request.
As with any leave, the LAO makes the final determination as to the scheduling and the amount of leave granted.
LEAVE BANK OFFICE
Upon receipt, the Leave Bank Case Manager will review the Leave Recipient Application to ensure that:
All of the documentation is included;
The applicant is a current NIH Leave Bank Member; and
The absence from duty without available paid leave because of the medical emergency is (or is expected to be) at
least 24 hours (or, in the case of a part-time employee or an employee with an uncommon tour of duty, at least 30
percent of the average number of hours in the employee's biweekly scheduled tour of duty).
The employee will receive notification from the Leave Bank Office’s “OHR SharePoint” email account that indicates the
status of the application and if more information is required to move the application forward. Applicants should expect
correspondence within one business day of submission.
NIH LEAVE BANK RECIPIENT APPLICATION PACKAGE
Leave Recipient Application for the NIH Leave Bank – Instructions
This form is used to apply to become a Leave Recipient under the NIH Voluntary Leave Bank Program (Leave Bank). All
Leave Recipients are subject to all leave provisions outlined in 5 C.F.R. Part 630, Subpart J and NIH Leave Bank Policies
and Procedures. This instructions page is not all inclusive, so applicants must also read the NIH Leave Bank Policies and
Procedures, available at http://hr.od.nih.gov/benefits/leave/vlbp/resources.htm. All applicants and Leave Approving
Officials (LAOs) are encouraged to contact the NIH Leave Bank Office with any questions or concerns at 301-443-8393
or leavebank@od.nih.gov.
A complete Leave Recipient Application Package must be submitted to the Leave Bank Office no later than 30 calendar
days following the termination of the medical emergency. The package must include:
NIH 2941, NIH Leave Bank Cover Sheet
NIH 2940, The Recipient Application for the NIH Leave Bank
NIH 2923, Authorization for Disclosure of Information
Primary Medical Documentation (see NIH 2923 instructions page)
APPLICANT INFORMATION
To initiate the Leave Recipient process, the applicant shall complete NIH 2940, Section A, and submit the NIH 2940
along with this instructions page to his/her Leave Approving Official (LAO). If the Leave Recipient Applicant is unable to
complete the NIH 2940, a personal representative may complete the forms on his/her behalf.
A.1 – Applicant Information
A.2 – Leave Bank Request Information
For cases with an unknown start date (i.e. transplant), provide the recovery duration (i.e. 8 weeks) instead of the end date.
For intermittent needs, indicate the number of hours per week, per month, or per year required by the medical emergency.
A.3 – FMLA Request Information
Medical need is determined through the NIH Leave Bank verification process.
LEAVE APPROVING OFFICIAL INSTRUCTIONS
The LAO shall complete all items in NIH 2940, Section B and return to the Leave Recipient Applicant within five
business days of receipt. The LAO does not need to know the medical emergency. All cases will be sent for medical
review.
The LAO should indicate how much time out of the office the organization can support by selecting the
appropriate box (yes, some, FMLA Only, or no). If the LAO plans to disapprove the employee’s possible absence from
duty, the LAO should contact his/her servicing Employee Relations Specialist to discuss leave policies. To find the
appropriate Employee Relations Specialist, visit
http://intrahr.od.nih.gov/policyguidance/er/contacts.htm
(NIH- only).
If an applicant invokes the Family and Medical Leave Act of 1993 (FMLA), the LAO must approve the application
unless he/she has reason to believe that the employee is not eligible for FMLA. Leave Bank Members do not have an
entitlement to use leave granted by the Leave Bank Board unless the employee is eligible for an invoked FMLA request.
As with any leave, the LAO makes the final determination as to the scheduling and the amount of leave granted.
LEAVE BANK OFFICE
Upon receipt, the Leave Bank Case Manager will review the Leave Recipient Application to ensure that:
All of the documentation is included;
The applicant is a current NIH Leave Bank Member; and
The absence from duty without available paid leave because of the medical emergency is (or is expected to be) at
least 24 hours (or, in the case of a part-time employee or an employee with an uncommon tour of duty, at least 30
percent of the average number of hours in the employee's biweekly scheduled tour of duty).
The employee will receive notification from the Leave Bank Office’s “OHR SharePoint” email account that indicates the
status of the application and if more information is required to move the application forward. Applicants should expect
correspondence within one business day of submission.
National Institutes of Health (NIH)
Leave Recipient Application for the NIH Leave Bank
You must read applicant instructions (attached) prior to completing this form. Please Print or Type.
SECTION A – APPLICANT
A.1 Applicant Information
Applicant Name (Title, First, MI, Last)
Institute
1.
2.
A.2 Leave Bank Request Information
Individual affected by medical emergency (check one)
If employee family member, specify:
3.
4.
Employee
Name:
Employee Family Member
Relationship:
Nature of the medical emergency:
Anticipated time out of the office due to the serious health condition
5.
6.
Start Date:
End Date:
The medical emergency is confidential. This item
Continuous
can be left blank until AFTER section B is complete.
Intermittent;
hours per
A.3 FMLA Request Information *cannot exceed 480 hours in a 12 month period
Do you wish to invoke FMLA?
Have you invoked FMLA within
Anticipated FMLA start date, end date and
7.
8.
9.
Yes
the last 12 months?
duration
No
Yes; date of first FMLA use:
Start Date:
End Date:
www.opm.gov/oca/fmla/index.asp
Continuous
No
Intermittent;
hours per
Attach memo, if necessary, to clarify dates/durations
I certify that the above statements are true
10.
Signature of applicant or individual applying on behalf of the applicant
Date
Applying on Behalf of the Applicant
11.
Applicant Representative’s Name
Relationship
Telephone Number
Privacy Act Statement
Participation in this program is voluntary; however, solicitation of this information is authorized by P.L. 103-103 (October 8, 1993). The information furnished will be
used to identify records property associated with the application to become a leave recipient. It may also be disclosed to a national, State, or local law enforcement
agency where there is an indication of a violation or potential violation of civil or criminal law, rule, or regulation; or to another agency or court when the Government
is party to a suit. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number (SSN). Furnishing the Social Number, as well as other data,
is voluntary, but failure to do so may delay or prevent action on the application.
SECTION B - LEAVE APPROVING OFFICIAL
Do you plan to approve the employee’s absence from duty in the
Complete only if “Employee” is selected in Item 3.
12.
13.
event this application is approved by the Leave Bank Board?
Level of physical exertion required by the position:
Information available at
Sedentary - lifts up to 10 lbs
www.hr.od.nih.gov/benefits/leave/VLBP.
Light - lifts up to 20 lbs
Yes
Medium - lifts up to 50 lbs
Some; from
to
or check box if FMLA leave only
Heavy - lifts up to 100 lbs
No; reason:
Very Heavy - lifts more than 100lbs
www.ssa.gov/OP_Home/cfr20/404/404-1567.htm
Leave Approving Official Signature
Date
Leave Approving Official Name (Last, First, MI)
Telephone Number
This signature does not entitle the employee to the leave that is granted by the Leave Bank Board. As with any leave, Leave Approving Officials make the final
determination as to the scheduling and the amount of leave granted.
SECTION C – NIH LEAVE BANK
Date of Receipt
14.
Approved
Disapproved
Incomplete
15.
Leave Bank Official’s Signature
Date
NIH Form 2940 (11/13)
Page of 2