GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 
Department of Human Services 
 
Office of Human Resources 
Personnel and Labor Relations 
 
 
EMPLOYEE FAMILY 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