(Family and Medical Leave Act, as made applicable by the Congressional Accountability Act)
FORM G
Notice to Employing Office
The Family and Medical Leave Act (FMLA), as made applicable by the Congressional Accountability Act (CAA), provides that an employing office may require an employee seeking military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran to submit a certification providing sufficient facts to support the request for leave. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations issued by the Office of Congressional Workplace Rights (OCWR) Board of Directors at 825.310. Employing offices must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees or employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files, if the Americans with Disabilities Act and/or the Genetic Information Nondiscrimination Act apply, as made applicable by the CAA.
SECTION I: For Completion by the EMPLOYEE and/or the VETERAN for whom the employee is requesting leave
INSTRUCTIONS to the EMPLOYEE and/or VETERAN: Please complete Section I before having Section II completed. The FMLA, as made applicable by the CAA, permits an employing office to require that an employee submit a timely, complete, and sufficient certification to support a request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If requested by the employing office, your response is required to obtain or retain the benefit of FMLA-protected leave. Failure to do so may result in a denial of an employee’s FMLA request. OCWR regulations at 825.310(g). The employing office must give an employee at least 15 calendar days to return this form to the employing office. (This section must be completed before Section II can be completed by a health care provider.)
