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FMLA Military Certification (Injury/Illness Veteran) with Tip Sheet - ComplyRight Mobile App

Updated to comply with the most recent FMLA regulations effective March 8, 2013

Use this attorney-developed form when an employee requests leave to take care of a family member who is a covered veteran with a serious injury or illness. FMLA Certifications are used to verify an employee’s need for FMLA leave and the existence of an FMLA-qualifying event. They help you gather the information you need to either grant or deny FMLA leave, without violating an employee’s privacy rights or overstepping legal boundaries. In each scenario, give your employee the blank certification form within five business days after learning about his or her need for leave, and allow the employee at least 15 days to return it. Click here for a free tip sheet that includes information on completing certifications, relevant FMLA definitions, helpful do’s and don’ts and other useful information.

Need printed FMLA Forms? Visit G.Neil for a printed version of the FMLA Military Certification (Injury/Illness Veteran) Form.

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Take a peek inside the FMLA Military Certification (Injury/Illness Veteran) with Tip Sheet - ComplyRight Mobile App

Included Features

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Included Fields

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  • Ico statictext

    (Injury/Illness Veteran)

  • Ico statictext

    (Certification for Serious Injury or Illness of Veteran for Military Family Leave)

  • Ico statictext

    Notice to the EMPLOYER

  • Ico statictext

    The Family and Medical Leave Act (FMLA) provides that you, as an employer, may require an employe...

  • Ico statictext

    In accordance with federal law, employers generally must maintain records and documents relating ...

  • Ico statictext

    Section I: For Completion by the EMPLOYEE and/or the Veteran

  • Ico statictext

    INSTRUCTIONS: Please complete Section I before having Section II completed.

  • Ico statictext

    PLEASE DO NOT PROVIDE GENETIC INFORMATION: The Genetic Information Nondiscrimination Act of 2008 ...

  • Ico statictext

    Section II: For Completion by: (1) A UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTHCARE PROV...

  • Ico statictext

    INSTRUCTIONS: The employee named in Section 1 has requested leave under the military caregiver le...

  • Ico statictext

    (i) a continuation of a serious injury or illness that was incurred or aggravated when the covere...

  • Ico statictext

    A complete and sufficient certification to support a request for FMLA military caregiver leave du...

  • Ico statictext

    PLEASE DO NOT PROVIDE GENETIC INFORMATION: The Genetic Information Nondiscrimination Act of 2008 ...

  • Ico statictext

    (Please complete Section I before having Section II completed by a healthcare provider.

  • Ico multiline

    Name and address of employer (this is the employer of the employee who is requesting leave to car...

  • Ico statictext

    Name of employee requesting leave to care for a veteran:

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    First

  • Ico textbox

    Middle

  • Ico textbox

    Last

  • Ico statictext

    Name of veteran (for whom employee is requesting leave):

  • Ico textbox

    First

  • Ico textbox

    Middle

  • Ico textbox

    Last

  • Ico dropdown

    Relationship of employee to veteran:

  • Ico textbox

    If Next of Kin, please specify relationship:

  • Ico date

    1. Date of the veteran's discharge:

  • Ico dropdown

    Was the veteran dishonorably discharged or released from the Armed Forces (including National Gu...

  • Ico multiline

    3. Please provide the veteran's miltary branch, rank and unit at the time of discharge:

  • ...and More!

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