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
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