NAVPERS Form 12600/4 "Bupers Civilian Employee Request for Leave Under the Family and Medical Leave Act"

What Is NAVPERS Form 12600/4?

This is a legal form that was released by the U.S. Department of the Navy - Navy Personnel Command on February 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest available edition released by the U.S. Department of the Navy - Navy Personnel Command;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of NAVPERS Form 12600/4 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Navy - Navy Personnel Command.

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Download NAVPERS Form 12600/4 "Bupers Civilian Employee Request for Leave Under the Family and Medical Leave Act"

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BUPERS CIVILIAN EMPLOYEE REQUEST FOR LEAVE UNDER THE FAMILY AND MEDICAL LEAVE ACT (FMLA)
NAVPERS 12600/4 (02-2018)
Supporting Directive BUPERSINST 12600.5
The Federal Government offers a wide range of leave options and workplace flexibilities to assist an employee who needs to be away from the
workplace. These flexibilities include annual leave, sick leave, advanced annual leave or advanced sick leave, donated leave under the voluntary
leave transfer program, leave without pay, alternative work schedules, credit hours under flexible work schedules, compensatory time off, and telework.
Handbook on Leave and Workplace Flexibilities for Childbirth, Adoption, and Foster Care
Handbook on Workplace Flexibilities and Work-Life Programs for Elder Care
The Family and Medical Leave Act (FMLA) provides up to 12 weeks (480 hours) of unpaid, job-protected leave in a 12-month period for your serious
health condition or the serious health condition of your spouse, son, daughter, or parent, or up to 26 weeks to care for a covered Service member with
a serious injury or illness. Time off under the FMLA may not be held against you in employment actions such as hiring, promotions or discipline.
Leave may be taken all at once, or may be taken intermittently as the medical condition stipulates.
FMLA leave in unpaid. However, if you have sick leave, annual leave, compensatory time, etc. accrued, you may use that paid leave time,
concurrently with your FMLA leave so that you continue to get paid.
Employee Name:
Activity/UIC:
Department:
Phone Number:
PART I: EMPLOYEE REASON FOR FMLA REQUEST
My own serious health condition.
WH-380-E Certification of Health Care Employee's Serious Health Condition is attached.
The birth of child(ren) and care thereof said child(ren) (either parent), or placement of a child with me for adoption or foster care.
WH-380-E Certification of Health Care Employee's Serious Health Condition is attached.
The need to provide care for the serious health condition of my:
WH-380-F Certification of Health Care Family Member's Serious Health Condition is attached.
A qualifying exigency for a Service member on covered active duty or call to covered active duty status with the Armed Forces
and I am the Service member's:
Active Duty Orders and WH-384 Certification of Qualifying Exigency for Military Family Leave is attached.
The need to provide care for a Service member with a serious injury or illness and I am the Service member's:
WH-385 Certification of Serious Injury of Illness of a Current Service member for Military Family Leave is attached.
Date the requested absence for the above purpose began or is scheduled to begin.
I have received a copy of The Employee's Guide to Family Medical Leave Act.
Yes
No
Employee Name:
Employee Signature:
Date:
PART II: SUPERVISORY RECOMMENDATION
Recommended
Not Recommended
1st Level Immediate Supervisor Name:
1st Level Immediate Supervisor Signature:
Date:
Recommended
Not Recommended
2nd Level Immediate Supervisor Name:
2nd Level Immediate Supervisor Signature:
Date:
PART III: TOTAL FORCE HUMAN RESOURCES AND MANPOWER OFFICE (BUPERS-05) USE ONLY
Employee is eligible for FMLA Leave
FMLA previously invoked:
Yes
No
Employee is NOT eligible for FMLA Leave because:
Employee does not meet the required FMLA 12-month service tour length.
Employee does not meet the required 1250 hours of service in the 12-months before requested leave start date.
PART IV: TOTAL FORCE HUMAN RESOURCES AND MANPOWER OFFICE (BUPERS-05) APPROVAL
Approved
Disapproved
Remarks:
BUPERS-05 Representative Name:
BUPERS-05 Representative Signature:
Date:
FOR OFFICIAL USE ONLY
Page 1 of 1
PRIVACY SENSITIVE
BUPERS CIVILIAN EMPLOYEE REQUEST FOR LEAVE UNDER THE FAMILY AND MEDICAL LEAVE ACT (FMLA)
NAVPERS 12600/4 (02-2018)
Supporting Directive BUPERSINST 12600.5
The Federal Government offers a wide range of leave options and workplace flexibilities to assist an employee who needs to be away from the
workplace. These flexibilities include annual leave, sick leave, advanced annual leave or advanced sick leave, donated leave under the voluntary
leave transfer program, leave without pay, alternative work schedules, credit hours under flexible work schedules, compensatory time off, and telework.
Handbook on Leave and Workplace Flexibilities for Childbirth, Adoption, and Foster Care
Handbook on Workplace Flexibilities and Work-Life Programs for Elder Care
The Family and Medical Leave Act (FMLA) provides up to 12 weeks (480 hours) of unpaid, job-protected leave in a 12-month period for your serious
health condition or the serious health condition of your spouse, son, daughter, or parent, or up to 26 weeks to care for a covered Service member with
a serious injury or illness. Time off under the FMLA may not be held against you in employment actions such as hiring, promotions or discipline.
Leave may be taken all at once, or may be taken intermittently as the medical condition stipulates.
FMLA leave in unpaid. However, if you have sick leave, annual leave, compensatory time, etc. accrued, you may use that paid leave time,
concurrently with your FMLA leave so that you continue to get paid.
Employee Name:
Activity/UIC:
Department:
Phone Number:
PART I: EMPLOYEE REASON FOR FMLA REQUEST
My own serious health condition.
WH-380-E Certification of Health Care Employee's Serious Health Condition is attached.
The birth of child(ren) and care thereof said child(ren) (either parent), or placement of a child with me for adoption or foster care.
WH-380-E Certification of Health Care Employee's Serious Health Condition is attached.
The need to provide care for the serious health condition of my:
WH-380-F Certification of Health Care Family Member's Serious Health Condition is attached.
A qualifying exigency for a Service member on covered active duty or call to covered active duty status with the Armed Forces
and I am the Service member's:
Active Duty Orders and WH-384 Certification of Qualifying Exigency for Military Family Leave is attached.
The need to provide care for a Service member with a serious injury or illness and I am the Service member's:
WH-385 Certification of Serious Injury of Illness of a Current Service member for Military Family Leave is attached.
Date the requested absence for the above purpose began or is scheduled to begin.
I have received a copy of The Employee's Guide to Family Medical Leave Act.
Yes
No
Employee Name:
Employee Signature:
Date:
PART II: SUPERVISORY RECOMMENDATION
Recommended
Not Recommended
1st Level Immediate Supervisor Name:
1st Level Immediate Supervisor Signature:
Date:
Recommended
Not Recommended
2nd Level Immediate Supervisor Name:
2nd Level Immediate Supervisor Signature:
Date:
PART III: TOTAL FORCE HUMAN RESOURCES AND MANPOWER OFFICE (BUPERS-05) USE ONLY
Employee is eligible for FMLA Leave
FMLA previously invoked:
Yes
No
Employee is NOT eligible for FMLA Leave because:
Employee does not meet the required FMLA 12-month service tour length.
Employee does not meet the required 1250 hours of service in the 12-months before requested leave start date.
PART IV: TOTAL FORCE HUMAN RESOURCES AND MANPOWER OFFICE (BUPERS-05) APPROVAL
Approved
Disapproved
Remarks:
BUPERS-05 Representative Name:
BUPERS-05 Representative Signature:
Date:
FOR OFFICIAL USE ONLY
Page 1 of 1
PRIVACY SENSITIVE