Certification Of Qualifying Exigency For Military Family Leave Form (Page 2 of 2) in pdf

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

Certification Of Qualifying Exigency For Military Family Leave Form Page 2