USVI Public Records

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EMPLOYEE REQUEST FOR FAMILY MEDICAL LEAVE Name: ____________________________________ Division: ___________________________________ Current Address: _________________________________________________________________ Phone: _____________________________ Email: ______________________________________ Start of Anticipated Leave: __________________________________________________________ Expected Return to Work Date: ______________________________________________________ Reason for Leave (Briefly Explain): _________________________________________________________ Self Family |Hours Requested: _____ Sick Leave Balance: ______ Annual Leave Balance: ______ Will donated leave be used? Yes No If yes, how many hours? ______________________ NOTE: An employee requesting leave for the employee's serious health condition or 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 failure to return to work at the end of my leave period may be treated 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 Employee should return form to HR with supporting documents *If required New Extension