GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES
GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Office of Human Resources Personnel and Labor Relations EMPLOYEE FMLA REQUEST FAMILY MEDICAL LEAVE APPLICATION FOR FAMILY MEDICAL LEAVE Name: Division: Current Address: Start of Anticipated Leave: Expected Date of Return to Work: Reason for Leave (Explain): _____________________________________________________ NOTE: Am employee requesting leave for the employee's serious health condition of the serious health condition of the employee's spouse, child or parent, must submit a verifying medical certification from a physician within 15 days of application for leave. I hereby authorize a health care provider or designee representing [The Government of the United States Virgin Islands] to contact my physician to verify the reason for my requested Family Medical Leave. I understand that a failure to return to work at the end of my leave period may be treate d as resignation / job abandonment unless an extension has been agreed upon and approved in writing by the Department of Human Services. …
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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Office of Human Resources Personnel and Labor Relations EMPLOYEE FMLA REQUEST FAMILY MEDICAL LEAVE APPLICATION FOR FAMILY MEDICAL LEAVE Name: Division: Current Address: Start of Anticipated Leave: Expected Date of Return to Work: Reason for Leave (Explain): _____________________________________________________ NOTE: Am employee requesting leave for the employee's serious health condition of the serious health condition of the employee's spouse, child or parent, must submit a verifying medical certification from a physician within 15 days of application for leave. I hereby authorize a health care provider or designee representing [The Government of the United States Virgin Islands] to contact my physician to verify the reason for my requested Family Medical Leave. I understand that a failure to return to work at the end of my leave period may be treate d as resignation / job abandonment unless an extension has been agreed upon and approved in writing by the Department of Human Services. Employee Signature Date APPROVED BY: Supervisor Date Administrator Date Deputy Commissioner, Human Resources & Labor Relations Date Commissioner Date