Form DOP-L8 "Certification for Qualifying Exigency for Military Family Leave - Federal Family and Medical Leave Act (Fmla)" - West Virginia

What Is Form DOP-L8?

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

Form Details:

  • Released on February 11, 2014;
  • The latest edition provided by the West Virginia Division of Personnel;
  • 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 DOP-L8 by clicking the link below or browse more documents and templates provided by the West Virginia Division of Personnel.

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STATE OF WEST VIRGINIA
FEDERAL FAMILY and MEDICAL LEAVE ACT (FMLA)
Certification for Qualifying Exigency for Military Family Leave
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. You may not ask the employee to provide more information
than allowed under the FMLA regulations, § 29 CFR 825.309.
Name and address for the employer of the person requesting leave due to a qualifying exigency:
EMPLOYER NAME:
EMPLOYER 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 CFR 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.
Name of employee requesting leave due to a qualifying exigency:
EMPLOYEE NAME (First, Middle/Middle Init., and Last):
Name of current servicemember on covered active duty or call to covered active duty status:
SERVICEMEMBER NAME (First, Middle/Middle Init., and Last):
Employee relationship to current member: ☐ Spouse
☐ Parent
☐ Son/Daughter
☐ Next of Kin
If Next of Kin, specify relationship:
Period of current servicemember’s covered active duty:
BEG. DATE:
END. DATE:
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes
written documentation confirming a current servicemember’s covered active duty or call to covered active duty
status. Please check one of the following and attach the indicated document to support that the current
servicemember is on covered active duty or call to covered active duty status.
☐ A copy of the current servicemember’s covered active duty orders is attached.
☐ Other documentation from the military certifying that the current servicemember 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 current
servicemember’s covered active duty or call to covered active duty status.
Form DOP-L8
Page 1 of 3
February 11, 2014
STATE OF WEST VIRGINIA
FEDERAL FAMILY and MEDICAL LEAVE ACT (FMLA)
Certification for Qualifying Exigency for Military Family Leave
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. You may not ask the employee to provide more information
than allowed under the FMLA regulations, § 29 CFR 825.309.
Name and address for the employer of the person requesting leave due to a qualifying exigency:
EMPLOYER NAME:
EMPLOYER 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 CFR 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.
Name of employee requesting leave due to a qualifying exigency:
EMPLOYEE NAME (First, Middle/Middle Init., and Last):
Name of current servicemember on covered active duty or call to covered active duty status:
SERVICEMEMBER NAME (First, Middle/Middle Init., and Last):
Employee relationship to current member: ☐ Spouse
☐ Parent
☐ Son/Daughter
☐ Next of Kin
If Next of Kin, specify relationship:
Period of current servicemember’s covered active duty:
BEG. DATE:
END. DATE:
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes
written documentation confirming a current servicemember’s covered active duty or call to covered active duty
status. Please check one of the following and attach the indicated document to support that the current
servicemember is on covered active duty or call to covered active duty status.
☐ A copy of the current servicemember’s covered active duty orders is attached.
☐ Other documentation from the military certifying that the current servicemember 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 current
servicemember’s covered active duty or call to covered active duty status.
Form DOP-L8
Page 1 of 3
February 11, 2014
PART A: QUALIFYING REASON FOR LEAVE
Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason
you are requesting leave):
☐Yes ☐ No
Is available written documentation supporting this request for leave attached? A complete
☐ None Available
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 current servicemember’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.
PART B: AMOUNT OF LEAVE NEEDED
Approximate date exigency commenced:
Probable duration of exigency:
☐Yes ☐ No
Will you need to be absent from work for a single continuous period of time due to the
qualifying exigency? If yes, estimate the beginning and ending dates for the period of
absence:
BEG. DATE:
END. DATE:
☐Yes ☐ No
Will you need to be absent from work periodically to address this qualifying exigency?
Estimate schedule of leave, including the dates of any scheduled meetings or appointments:
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time
(i.e. , 1 deployment-related meeting every month lasting 4 hours):
Frequency: ______ times per ______ week(s) ______ month(s)
Duration: ______ hours ______ day(s) per event
PART C: MEETINGS AND OTHER EVENTS
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 current servicemember’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
STATE OF WEST VIRGINIA
February 11, 2014
FEDERAL FAMILY and MEDICAL LEAVE ACT (FMLA)
Form DOP-L8
Certification for Qualifying Exigency – for Military Family Leave
Page 2 of 3
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: CERTIFICATION AND SIGNATURE
I certify that the information I provided above is true and correct.
Employee Signature: ______________________________________________ Date: _____________________
STATE OF WEST VIRGINIA
February 11, 2014
FEDERAL FAMILY and MEDICAL LEAVE ACT (FMLA)
Form DOP-L8
Certification for Qualifying Exigency – for Military Family Leave
Page 3 of 3
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