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