"Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act)" - Delaware

Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act) is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

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State of Delaware
Department of Human Resources
Certification of Qualifying Exigency for Military Family Leave
(Family and Medical Leave Act)
Authority: The Family and Medical Leave Act
Policy #: To be assigned.
of 1993, as amended February 25, 2015; M.R. 5.7
Effective Date: November 20, 2019
Supersedes: March 2013
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)
Agency Name: __________________________________________________________________________
Agency Address: _________________________________________________________________________
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 military member on covered active duty or call to covered active duty status:
____________________________________________________________________________________________________________
First
Middle
Last
Relationship of military member to you: _______________________________________________________
Period of 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 military member’s covered active duty or call to covered active duty status. Please
check one (1) 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 military member’s covered active duty orders is attached.
_____ Other documentation from the military certifying that the military member is on covered active duty (or has
been notified of an impending call to covered active duty) is attached.
_____ I have previously provided my employer with sufficient written documentation confirming the military
member’s covered active duty or call to covered active duty status.
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State of Delaware
Department of Human Resources
Certification of Qualifying Exigency for Military Family Leave
(Family and Medical Leave Act)
Authority: The Family and Medical Leave Act
Policy #: To be assigned.
of 1993, as amended February 25, 2015; M.R. 5.7
Effective Date: November 20, 2019
Supersedes: March 2013
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)
Agency Name: __________________________________________________________________________
Agency Address: _________________________________________________________________________
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 military member on covered active duty or call to covered active duty status:
____________________________________________________________________________________________________________
First
Middle
Last
Relationship of military member to you: _______________________________________________________
Period of 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 military member’s covered active duty or call to covered active duty status. Please
check one (1) 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 military member’s covered active duty orders is attached.
_____ Other documentation from the military certifying that the military member is on covered active duty (or has
been notified of an impending call to covered active duty) is attached.
_____ I have previously provided my employer with sufficient written documentation confirming the military
member’s covered active duty or call to covered active duty status.
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Certification of Qualifying Exigency for Military Family Leave
Policy#: To be assigned.
Rev. Date:
(Family and Medical Leave Act)
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?
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time
(i.e., one (1) deployment-related meeting every month lasting four (4) hours):
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours _____ day(s) per event.
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Certification of Qualifying Exigency for Military Family Leave
Policy #: To be assigned.
(Family and Medical Leave Act)
Rev. Date:
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, childcare or parental care providers, to make financial or legal
arrangements, to act as the 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.
For Agency Use Only
Date Issued to Employee:
Date Returned by Employee:
Date Approved:
Date Denied:
Date Returned to Employee for
additional information:
Reviewed by:
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