Certification of Qualifying Exigency for Military Family Leave Form - New Mexico

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Certification of Qualifying Exigency for Military Family Leave Form
(UNMH Policy 175 – Family and Medical Leave)
Section I. For Completion by the EMPLOYEE.
INSTRUCTIONS TO EMPLOYEE: Please complete Section I fully and completely. UNMH requires
that you submit a timely, complete, and sufficient medical 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 benefits. While you are not required to provide this information, failure to do so may result in a
denial of your request for FMLA leave.
Employee Name:______________________________________________________________________
Name of covered military member: ________________________________________________________
Relationship to you of the covered military member: __________________________________________
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
included 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 supervisor 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. QUALFYING REASON FOR LEAVE
1. Describe the reason you are requesting FMLA leave due to a qualifying exigency (include 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 briefing 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: No Yes  Not Available
PART B. AMOUNT OF LEAVE NEEDED
1. Approximate date exigency commenced: _______________________________________________
Probable duration of exigency: ________________________________________________________
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Certification of Qualifying Exigency for Military Family Leave Form
(UNMH Policy 175 – Family and Medical Leave)
Section I. For Completion by the EMPLOYEE.
INSTRUCTIONS TO EMPLOYEE: Please complete Section I fully and completely. UNMH requires
that you submit a timely, complete, and sufficient medical 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 benefits. While you are not required to provide this information, failure to do so may result in a
denial of your request for FMLA leave.
Employee Name:______________________________________________________________________
Name of covered military member: ________________________________________________________
Relationship to you of the covered military member: __________________________________________
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
included 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 supervisor 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. QUALFYING REASON FOR LEAVE
1. Describe the reason you are requesting FMLA leave due to a qualifying exigency (include 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 briefing 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: No Yes  Not Available
PART B. AMOUNT OF LEAVE NEEDED
1. Approximate date exigency commenced: _______________________________________________
Probable duration of exigency: ________________________________________________________
C
O
N
P
ONTINUED
N
EXT
AGE
1
Certification of Qualifying Exigency for Military Family Leave Form
(UNMH Policy 175 – Family and Medical Leave)
2. Will you need to be absent from work for a single continuous period of time due to the qualifying
exigency? No Yes
If yes, 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? No Yes
Estimate schedule of leave, including the dates of any scheduled meeting 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 last 4 hours):
Frequency: _____ time per _____ week(s) OR _____ month(s)
Duration: _____ hours OR _____ day(s) per event
PART C: THIRD-PARTY MEETINGS
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 purpose 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
UNMH to verify the accuracy of the information contained on this form.
Name of Individual: _____________________________ Title: __________________________________
Organization: ________________________________________________________________________
Address: ____________________________________________________________________________
Telephone: (
)___________________________________ Fax: ______________________________
Email: ______________________________________________________________________________
Describe nature of meeting: _____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
I certify that the information I provided above is true and correct.
___________________________________________________________________________________
Signature of Employee
Date
2

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