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Certification for Serious Injury or Illness of Covered Service member for Military Family Leave (Family and Medical Leave Act) U.S. Department of Labor Wage and Hour Division OMB Control Number: 12150181
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How to fill out of a covered servicemember
How to fill out a covered servicemember:
01
Gather the necessary information: Start by collecting the required details for filling out the form. This might include the servicemember's name, rank, branch of service, and contact information.
02
Identify the purpose: Understand why you are filling out the form. It could be for various reasons, such as healthcare benefits, military leave, or other related services. Knowing the purpose will help you provide accurate information.
03
Provide personal information: Fill out the form with the servicemember's personal details, such as their social security number, date of birth, address, and dependents' information if applicable.
04
Specify military status: Indicate the servicemember's current military status, including whether they are active duty, National Guard, Reserve, or retired.
05
Document deployment information: If the servicemember is currently deployed or has been deployed in the past, provide the necessary deployment details, such as deployment dates, location, and any supporting documents required.
06
Include point of contact: Specify someone who can be contacted in case of emergencies or to obtain additional information, such as a next of kin or designated representative.
07
Sign and date the form: Complete the form by signing and dating it. Make sure all the information provided is accurate and up to date.
Who needs a covered servicemember:
01
Military families: Spouses, children, and other dependents of servicemembers often require the services and benefits provided by a covered servicemember. It ensures they can access healthcare, receive support during deployments, and avail other military-related assistance.
02
Employers: Employers of servicemembers may need to document the status of a covered servicemember to comply with employment laws, such as the Uniformed Services Employment and Reemployment Rights Act (USERRA). This allows them to understand the servicemember's employment rights and provide necessary support.
03
Government agencies: Various government entities, such as the Department of Defense, Department of Veterans Affairs, and other military branches, make use of the information provided in a covered servicemember form to administer benefits, services, and support for servicemembers and their families.
Overall, the completion of a covered servicemember form is crucial for ensuring accurate record-keeping, accessing services, and providing necessary support for servicemembers and their families.
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What is of a covered servicemember?
A covered servicemember is an individual who is a member of the armed forces, including the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty.
Who is required to file of a covered servicemember?
Employers are required to file for a covered servicemember under the Family and Medical Leave Act (FMLA).
How to fill out of a covered servicemember?
Employers must complete the FMLA paperwork for a covered servicemember and submit it to the appropriate department within the specified timeframe.
What is the purpose of of a covered servicemember?
The purpose of filing for a covered servicemember is to provide job-protected leave for eligible employees to care for a covered servicemember with a serious injury or illness.
What information must be reported on of a covered servicemember?
Employers must report the name of the covered servicemember, their relationship to the employee, the date the serious injury or illness occurred, and the expected duration of the leave.
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