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City of St. Louis Department of Personnel Administrative Regulation NO. 133-FORM |
The City of St. Louis Administrative Regulations have been converted to electronic format by the staff of the St. Louis Public Library. This electronic version has been done for the interest and convenience of the user. These are unofficial versions and should be used as unofficial copies.
Official printed copies of the City of St. Louis Administrative Regulations may be obtained from the Personnel Office at 1114 Market Street, Room 703, St. Louis, Missouri 63101.
Date Issued: ___________________
CITY OF ST. LOUIS
CERTIFICATION OF 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.
Employer Name: _________________________________________________________
Contact Information: ______________________________________________________
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. 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.
Your Name:
_____________________________________________________________
First
Middle
Last
Name of covered military member on active duty or call to
active duty status in support of a contingency operation:
________________________________________________________________________
First
Middle
Last
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 docu-
mentation 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).____________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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 announce-
ment 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
sup-
porting 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? No ____ Yes____.
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? No ____ Yes ____
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: ____ time per ____ week(s) ____ month(s)
Duration: ____ hours ____ day(s) per event.
PART C:
If leave is requested to meet with a third party (such as to
arrange for childcare; 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 the
form is accurate.
Name of Individual:
_______________________________________________________
Title: ___________________________________________________________________
Department/Division: ______________________________________________________
Address: ________________________________________________________________
Telephone: ( ) _________________________ Fax: ( ) ________________________
Email: __________________________________________________________________
Describe nature of meeting: _________________________________________________
______________________________________________________________________
PART D:
I certify that the information I provided above is true and correct.
________________________________________________
_____________________
Signature of Employee Date
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