GCBDA/GDBDA-AR(6) – Oregon Military Family Leave

(Leave due to notification of impending call to active duty or deployment)

Section 1: (To be completed by the district)

The Oregon Military Family Leave Act (OMFLA) provides that a district may require an employee seeking OMFLA leave due to notification of impending call to active duty or deployment, to submit a notification of the intention to take leave within five business days of receiving official notice.

District Name and Address:

Superintendent or designee information:

Section 2: (To be completed by the employee)

Complete the information below fully and completely. The Oregon Military Family Leave Act permits the district to require that you submit a timely, complete and sufficient notification for Oregon Military Family Leave Act due to notification of impending call to active duty or deployment.

Employee’s Name: First Middle Last

Name of covered military member on active duty, called to active duty status or deployed:

First Middle Last

Relationship of covered military member to you:

Period of covered military member’s impending call to active duty or deployment:

Documentation to support a request for Oregon Military Family leave includes written documentation confirming a covered military member’s active duty, call to active duty or deployment status. Please check one of the following and attach the indicated document to support that the military member is on covered active duty or called to covered active duty status:

• □ A copy of the covered military member’s active duty orders is attached.
• □ Other documentation from the military certifying that the covered military member is on active duty (or has been notified of an impending call to active duty).
• □ I have previously provided the district with sufficient written documentation confirming the covered military member’s active duty or call to active duty status.

Part A: Qualifying Reason for Leave

1. Describe the reason you are requesting OMFLA (include the specific reason below, either a) an impending call or order to active duty, or b) impending leave for deployment):

Part B: Amount of Leave Needed

1. The approximate date the active duty or deployment commenced or will commence is:

The probable duration of such active duty or deployment:

2. Will you need to be absent from work for a single continuous period of time due to the active duty or deployment? ☐ Yes ☐ No

If yes, estimate the beginning and ending dates for the period of absence:

3. Will you need to be absent from work periodically to address this active duty or deployment?

• ☐ Yes ☐ No

If yes, estimate the schedule of leave, including the dates of any scheduled meetings or appointments:

Part D: Employee Signature

I certify that the information I provided above is true and correct. (For Oregon Military Family Leave purposes, notice must be given by the employee within five business days of receiving an official notice.)

Signature of Employee Date