Intent to Apply for Paid Medical, Caregiver, and Parental Leave

Enter your full name.

Select your current training program.

Select the reason for your PMPC leave request

ParentalMedicalCaregiver

Enter the tentative start date for your leave of absence.

Enter the number of days you plan to take off during your leave of absence.

Have you been employed by CAMC less than 365 days?

YesNo

Since I have been employed by CAMC less than 365 days, I understand that I must have the Medical Certification form completed by the physician providing care to the patient for which leave is being taken. Link to the required Medical Certification Form: PMPC Medical Certification Form - For trainees with less than1 year employment only.docx

By checking the box I am indicating that I understand it is my responsibility to have the form completed and to submit the form to employee health.

Since I have been employed by CAMC for one year, I understand that I must apply for family medical leave to complete the medical certification process. You will need to contact the FML intake line at (304) 388-3924 to start the medical certification process.

By checking the box I am indicating that I understand it is my responsibility to contact the FML intake line and to complete the medical certification process.

Failure to complete the medical certification process may result in use of vacation/sick/wellness leave, unintended extension of training due to certification board or other accreditation body requirements.

By checking the box I am indicating that I understand failure to complete the medical certification process may result in use of vacation/sick/wellness leave, unintended extension of training due to certification board or other accreditation body requirements.

hidden calculated field - program