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

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

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  • Released on July 1, 2009;
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State of Alaska
Certification of Qualifying Exigency For Military
Division of Personnel & Labor Relations
Family Leave (Family and Medical Leave Act)
PO Box 110201
Juneau, AK 99811-0201
It is State of Alaska policy to invoke family leave for all qualifying exigencies. The supervisor, or designee, is responsible
for initially identifying a qualifying condition and for notifying an employee of his/her conditional family leave entitlement.
SECTION I: FOR COMPLETION BY THE SUPERVISOR
INSTRUCTIONS to the SUPERVISOR: 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 C.F.R. § 825.309. This form complies with this requirement and the use of this form is encouraged.
Supervisor name:
Contact Information:
SECTION II: FOR COMPLETION BY THE EMPLOYEE
Name of Employee:
Department:
Employee ID Number:
Please complete 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. 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.
Name of covered military member on active duty or call to active duty status in support of a contingency operation:
Relationship of covered military member to you:
Period of covered military member’s active duty:
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written
documentation confirming a covered military member’s active duty or call to active duty status in support of a contingency
operation. Please check one of the following:
A copy of the covered military member’s active duty orders is attached.
Other documentation from the military certifying that the covered military member is on active duty (or has been
notified of an impending call to active duty) in support of a contingency operation is attached.
I have previously provided my employer with sufficient written documentation confirming the covered military member’s
active duty or call to active duty status in support of a contingency operation.
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):
Revised 07/09
Page 1 of 2
State of Alaska
Certification of Qualifying Exigency For Military
Division of Personnel & Labor Relations
Family Leave (Family and Medical Leave Act)
PO Box 110201
Juneau, AK 99811-0201
It is State of Alaska policy to invoke family leave for all qualifying exigencies. The supervisor, or designee, is responsible
for initially identifying a qualifying condition and for notifying an employee of his/her conditional family leave entitlement.
SECTION I: FOR COMPLETION BY THE SUPERVISOR
INSTRUCTIONS to the SUPERVISOR: 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 C.F.R. § 825.309. This form complies with this requirement and the use of this form is encouraged.
Supervisor name:
Contact Information:
SECTION II: FOR COMPLETION BY THE EMPLOYEE
Name of Employee:
Department:
Employee ID Number:
Please complete 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. 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.
Name of covered military member on active duty or call to active duty status in support of a contingency operation:
Relationship of covered military member to you:
Period of covered military member’s active duty:
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written
documentation confirming a covered military member’s active duty or call to active duty status in support of a contingency
operation. Please check one of the following:
A copy of the covered military member’s active duty orders is attached.
Other documentation from the military certifying that the covered military member is on active duty (or has been
notified of an impending call to active duty) in support of a contingency operation is attached.
I have previously provided my employer with sufficient written documentation confirming the covered military member’s
active duty or call to active duty status in support of a contingency operation.
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):
Revised 07/09
Page 1 of 2
State of Alaska
Certification of Qualifying Exigency For Military
Division of Personnel & Labor Relations
Family Leave (Family and Medical Leave Act)
PO Box 110201
Juneau, AK 99811-0201
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 an appointment with a
counselor or school official, 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?
Yes
No
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: ADDITIONAL INFORMATION
If leave is requested to meet with a third party (such as to arrange for childcare, to attend counseling, to attend meetings with
school or childcare providers, to make financial or legal arrangements, to act as the covered 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: SIGNATURE
I certify that the information I provided above is true and correct.
Signature of Employee
Date
Revised 07/09
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