Form NPD-60 "Fmla Leave of Absence Form" - Nevada

What Is Form NPD-60?

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

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Nevada Department of Administration;
  • 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 printable version of Form NPD-60 by clicking the link below or browse more documents and templates provided by the Nevada Department of Administration.

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Download Form NPD-60 "Fmla Leave of Absence Form" - Nevada

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STATE OF NEVADA - FMLA LEAVE OF ABSENCE FORM
Part A. Employee Information
Employee's Name:
Employee ID #:
(Last)
(First)
(MI)
Address:
Class Title:
Full-Time:
Part-Time:
Agency Name:
Budget Acct #:
Position Ctrl #:
Part B. Leave Dates (Continuous or Intermittent)
Estimated Leave Start Date:
Estimated Date of Return:
Leave is requested on an intermittent or reduced leave schedule. Indicate the days of the week and/or hours during the day you
will be absent:
Anticipate using short or long term disability benefit during leave.
Part C. Reason for Leave
Leave for my own serious health condition (briefly describe):
Leave for the birth of a child or placement of a child for adoption or foster care. Indicate the expected date of birth or placement:
Spouse is employed by the State of Nevada:
YES
NO
(Date)
Leave to care for a family member with a serious health condition. Specify the family member’s name and relationship to you:
(Name)
(Relationship to You)
Leave because of a qualifying exigency arising out of the fact that your
spouse/
son or daughter/
parent is on covered
active duty or a call to covered active duty status with the Armed Forces. Specify the covered military member’s name:
(Name)
Leave to care for a
spouse/
son or daughter/
parent/
next of kin of a covered servicemember with a serious injury or
illness. Specify the covered servicemember’s name: ___________________________________________________________
Current servicemember?
Required certification form is attached. (Form NPD-83, WH-380-F, WH-384, WH-385, or WH-385-V)
Documentation to establish required relationship between employee and covered individual (if applicable) is attached.
(Signature of Employee or Designee)
(Date)
(If employee is not available to sign request, note verbal conversation above. Include date of the conversation and the signature of the person who completed the form.)
FMLA Leave of Absence Form
NPD-60
Page 1 of 1
Rev. 1.14
STATE OF NEVADA - FMLA LEAVE OF ABSENCE FORM
Part A. Employee Information
Employee's Name:
Employee ID #:
(Last)
(First)
(MI)
Address:
Class Title:
Full-Time:
Part-Time:
Agency Name:
Budget Acct #:
Position Ctrl #:
Part B. Leave Dates (Continuous or Intermittent)
Estimated Leave Start Date:
Estimated Date of Return:
Leave is requested on an intermittent or reduced leave schedule. Indicate the days of the week and/or hours during the day you
will be absent:
Anticipate using short or long term disability benefit during leave.
Part C. Reason for Leave
Leave for my own serious health condition (briefly describe):
Leave for the birth of a child or placement of a child for adoption or foster care. Indicate the expected date of birth or placement:
Spouse is employed by the State of Nevada:
YES
NO
(Date)
Leave to care for a family member with a serious health condition. Specify the family member’s name and relationship to you:
(Name)
(Relationship to You)
Leave because of a qualifying exigency arising out of the fact that your
spouse/
son or daughter/
parent is on covered
active duty or a call to covered active duty status with the Armed Forces. Specify the covered military member’s name:
(Name)
Leave to care for a
spouse/
son or daughter/
parent/
next of kin of a covered servicemember with a serious injury or
illness. Specify the covered servicemember’s name: ___________________________________________________________
Current servicemember?
Required certification form is attached. (Form NPD-83, WH-380-F, WH-384, WH-385, or WH-385-V)
Documentation to establish required relationship between employee and covered individual (if applicable) is attached.
(Signature of Employee or Designee)
(Date)
(If employee is not available to sign request, note verbal conversation above. Include date of the conversation and the signature of the person who completed the form.)
FMLA Leave of Absence Form
NPD-60
Page 1 of 1
Rev. 1.14