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ATTENTION:
PLEASE NOTE: IF YOU EXPERIENCE ANY ISSUES AND/OR ARE UNABLE TO DOWNLOAD THESE FORMS, PLEASE CONTACT LINDA BRUNO, PERSONNEL MANAGER, (LBRUNO@UMASD.ORG) OR VIEW FORMS ON UNITED STATES DEPARTMENT OF LABOR WEBPAGE:
https://www.dol.gov/agencies/whd/fmla/forms
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FAMILY / MEDICAL LEAVE OF ABSENCE COVERSHEET
This form must be accompanied by one of the five (5) Certification of Health Care Provider forms listed below. -
A. Employee's Serious Health Condition (WH-380-E)
Use when a leave request is due to the medical condition of the employee.
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B. Family Member's Serious Health Condition (WH-380-F)
Use when a leave request is due to the medical condition of the employee's family member.
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C. Qualifying Exigency for Military Family Leave (WH-384)
Use when the leave request arises out of the foreign deployment of the employee's spouse, son, daughter or parent.
FMLA WH-384 -Military Family Leave for Qualifying Exigency.pdf 306.81 KB (Last Modified on November 21, 2023) -
D. Military Caregiver Leave of a Current Servicemember (WH-385)
Use when requesting leave to care for a family member who is a current service member with a serious injury or illness.
FMLA WH385 Current Servicemember for Military Caregiver Leave.pdf 326.12 KB (Last Modified on February 16, 2024) -
E. Military Caregiver Leave of a Veteran (WH-385-V)
Use when requesting leave to care for a family member who is a covered veteran with a serious injury or illness.
FMLA WH385V Certification for Serious Injury or Illness of Veteran for Military Caregiver Leave.pdf 359.06 KB (Last Modified on February 16, 2024)