REQUEST FOR FAMILY OR MEDICAL LEAVE
_____________________________________________________________________________________________________
A request for family or medical leave should be made as soon as possible prior to the date requested leave is to begin.
Name: ____________________________________
Date:
__________________
Department: __________________________________________________
Status: Full-time______ Part-time _______
_________________________________________________________________________________________________
I request family or medical leave for the following reason(s):
Birth of a child*
Expected date of birth: ________________________
Leave start date: __________
Expected return date ____________________
Placement of a child with me for adoption or foster care* Placement date _________________
Leave start date: __________
Expected return date ____________________
To care for my spouse, child, or parent that has a serious health condition*
Leave start date: __________
Expected return date ____________________
For a serious health condition that makes me unable to perform my work duties*
Please describe:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Leave start date: __________
Expected return date ____________________
For other reasons*
Please describe: ________________________________________________________________________________
____________________________________________________________________________________________
Leave start date: __________
Expected return date ____________________
Requested intermittent leave schedule** (subject to agency's approval)
Schedule requested: ___________________________________________________________________________
Requested reduced schedule** (subject to agency's approval)
Schedule requested: __________________________________________________________________________
Have you taken family or medical leave in this current calendar year?
YES
NO
I understand and agree to the following provisions:

I have worked for state government (agency, if wage employee) for at least 12 months and for at least 1,250 hours in the previous
12 months.

I have the option of using paid leave for absences covered under family and medical leave. I understand CVCC can designate
such leave as family and medical leave.

If the leave will be unpaid (LWOP), I understand it will be my responsibility to pay my portion of the health care premium to my
agency on the first day of each month. Additionally, I understand that while on LWOP or after 60 consecutive work days of paid
leave I will not accrue annual or sick leave hours.

If, after 12 weeks of leave, I do not return to work on the date intended, CVCC may seek to recover the Commonwealth's health
insurance contributions for the period I was on leave without pay.

At the end of family and medical leave, I normally will be reinstated to my original position (or equivalent position) before the
leave began unless I hold a key position.
Employee Signature _____________________________________ Date __________________________
_____________________________________________________________________________________________________
LEAVE APPROVAL
Full Day(s) Leave:
Supervisor’s Signature __________________________________ Date_____________________
Vice President’s Signature _______________________________ Date ____________________
Intermittent Leave:
Supervisor’s Signature __________________________________ Date ____________________
Vice President’s Signature _______________________________ Date ____________________
Reduced Schedule Leave:
Supervisor’s Signature ___________________________________ Date __________________
Vice President’s Signature ________________________________ Date __________________
Human Resource Manager’s Signature _______________________ Date __________________
Notes: _____________________________________________________________________________________________
________________________________________________________________________________________________
* A physician's certification or other documentation may be required.
** Can be utilized only if you or your spouse, child, or parent has a serious health condition (and to care for a newborn or a child
placed with employee by adoption or foster care).
Certification of Health Care Provider Form
Family and Medical Leave Act of 1993
Employee’s Name:
Patient’s Name (if different from employee)
Employee’s Department:
Patient’s Relationship to Employee:
Do you believe the physical presence of the employee named above is necessary or beneficial in the care of the patient?
Yes
No
If Yes, for how long?
The Following is to be Completed by the Attending Physician or Practitioner:
The information requested on this form relates only to the serious health condition for which the employee is requesting leave under
the Family and Medical Leave Act. Please check the applicable category of the patient’s qualifying condition. NOTE:
Definitions on Reverse Side of This Form
Hospital Care
Admission to Hospital Date:
Discharge Date:
Acute Condition (Absence Plus Treatment)
Birth of a Child
Estimated Date of Delivery
Request for Mother
Request for Father
Chronic/Permanent Expected frequency of absence:
Lasting
days per month
hours per absence
1. Length of time your patient has had/will have this condition: From:
(keeping the employee from essential function of his/her job.)
Through:
2. Describe the regimen of treatment to be prescribed indicating the number of visits, general nature and duration of
treatment, including referral to other provider(s) of health services.
Include schedule of visits or treatment, if medically necessary for the employee to be off work on an intermittent basis or to work less
than the employee’s normal schedule of hours per day or days per week.
Print or Type Name of Healthcare Provider
Signature of Healthcare Provider
Type of Practice
Street and Mailing Address
Telephone Number
FAX Number
Physician Signature
Date
Please Return the Completed Form to:
Human Resources, CVCC, 3506 Wards Road, Lynchburg, VA 24502-2498
Definitions for Purposes of FMLA
1.
Incapacity: the inability to work, attend school or perform other regular daily activities due to the serious health
condition and treatment for or recovery from.
2.
Treatment: includes examinations to determine if a serious health condition exists and evaluations of the
condition but does not include routine physical and eye or dental examinations.
3.
A Regimen of Continuing Treatment: includes, for example, a course of prescription medication (e.g., an
antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of
treatment does not include the taking of over-the-counter medications, such as aspirin or antihistamines that
can be initiated without a visit to a health care provider.
4.
Serious Health Condition: an illness, injury, impairment or physical or mental condition involving hospital
care, absence plus treatment, pregnancy, a chronic condition requiring treatment or permanent/long term
conditions requiring supervision, as described above.
5.
Hospital Care: Inpatient care (an overnight stay) in a hospital, hospice or residential medical care facility,
including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient
care.
6.
Absence Plus Treatment: A period of incapacity of more than three consecutive calendar days (including any
subsequent treatment or period or incapacity relating to the same condition) which also involves:

Treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct
supervision of a health care provider or by a provider of health care services (e.g., physical therapist) under
orders of or on referral by a health care provider; or

Treatment by a health care provider on at least one occasion which results in a regimen of continuing
treatment under the supervision of health care provider.
7.
Pregnancy: A period of incapacity due to pregnancy or for prenatal care
8.
Chronic Conditions Requiring Treatment: A chronic condition which:



Requires periodic visits for treatment by a health care provider or by a nurse or physician’s assistant under
direct supervision of a health care provider;
Continues over an extended period of time (including recurring episodes of a single underlying condition);
May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
9.
Permanent/Long Term Conditions Requiring Supervision:

A period of incapacity which is permanent or long-term due to a condition for which treatment may not be
effective. The employee or family member must be under the continuing supervision of, but need not be
receiving, active treatment by a health care provider. Examples include Alzheimer’s, a severe stroke, or the
terminal stages of a disease.