Serious Health Condition Certification



Family Medical Leave ActRequest for Intermittent or Reduced-time Unpaid FMLA/SPF Absence After 12 Weeks for a Catastrophic Illness/InjuryEmployeeEmployee Personnel NumberTelephone Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AgencyWork Location FORMTEXT ????? FORMTEXT ?????Supervisor NameTimekeeper Name (optional) FORMTEXT ????? FORMTEXT ?????The intermittent or reduced-time FMLA/SPF absence will be used to cover absences from:From Date TOTo DateEmployee SignatureDateHuman Resources OfficeDate when ALL accrued and anticipated leave was exhausted:Review and check the following statements: FORMCHECKBOX In the past six-month period, the employee has not:been placed on a written leave restrictionreceived a written reprimand related to attendancereceived a suspension related to attendance FORMCHECKBOX The absences were not due to a work-related illness/injury.I recommend: FORMCHECKBOX Approval FORMCHECKBOX DisapprovalSignature of HR Director or FMLA/SPF CoordinatorDateOFFICE OF ADMINISTRATION FORMCHECKBOX Request is approved through the following date: ___________ FORMCHECKBOX Request is denied because:_________________________________________________________ Secretary of Administration DesigneeDatePlease return this form to: FORMTEXT ?????, FMLA/SPF Coordinator FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ????? FORMTEXT ................
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