Leave – Family, Medical & Servicemember (6.22.12)
PURPOSE
In compliance with the Family and Medical Leave Act of 1993, as amended, (“FMLA” or “the Act”) it is the
policy of Tennessee State University to provide eligible employees up to 12 workweeks of leave during a 12-
month period for family or medical leave, or for a qualifying exigency; or, up to 26 workweeks of leave for
military caregiver leave during a 12-month period for reasons specified in this Policy, to provide continued
health insurance coverage during the leave period and to insure employee reinstatement to the same or an
equivalent position following the leave period.
POLICY
Please refer to TBR Policy 5:01:01:14, Family, Medical & Servicemember Leave, for the most recent
information.
PROCEDURE
Form - Family and Medical Leave Act (FMLA) Request Form
Form – WH-380-E Certification of Health Care Provider for Employee’s Serious Health Condition (PDF)
Form – WH-380-F Certification of Health Care Provider for Family Member’s Serious Health Condition (PDF)
Form – WH-381 Notice of Eligibility and Rights and Responsibilities (PDF)
Form – WH-382 Designation Notice (PDF)
Form – WH-384 Certification of Qualifying Exigency for Military Family Leave (PDF)
Form – WH-385 Certification for Serious Injury or Illness of Current Servicemember – for Military Family
Leave (PDF)
Form – WH-385-V Certification for Serious Injury or Illness of a Veteran for Military Caregive Leave (PDF)
REFERENCE
