<table>
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<tbody>
<tr class="odd">
<td colspan="2"><p><em>BPA F 3510.04e</em></p>
<p><em>(08-03)</em></p></td>
<td colspan="6"><p><strong>U.S. DEPARTMENT OF ENERGY</strong></p>
<p><strong>BONNEVILLE POWER ADMINISTRATION</strong></p></td>
<td><p><em>Electronic Form Approved</em></p>
<p><em>by CIEP – 08/08/2003</em></p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="9"><strong>APPLICATION/NOTICE FOR LEAVE UNDER THE FAMILY
AND MEDICAL LEAVE ACT (FMLA)</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"><strong><u>APPLICATION FOR LEAVE UNDER
FMLA:</u></strong> To apply for leave under FMLA, an employee must
specifically invoke his/her entitlement by completing this form and the
Certification of Health Care Provider form BPA 3780.02e. Employees
should provide notice to manager at least <u>30 days prior</u> to the
date leave is to begin, if possible. <em>(Personnel Letter 630-1,
Chapter 8, Section H)</em> After FMLA entitlement is initially approved,
as indicated on this form, the employee must submit OPM Form 71 checking
the appropriate reason in Box 5, and indicating the type of leave
requested to cover the period of time the employee will be away from
work.</td>
</tr>
<tr class="even">
<td colspan="10"><strong>ELIGIBILITY:</strong> All employees who have
completed at least 12 months of service <em>(not required to be recent
or consecutive months)</em> are eligible except: (1) those serving under
temporary appointments with a time limitation of 1 year or less; and (2)
those with intermittent work schedules. <em>(Personnel Letter 630-1,
Chapter 8, Section B.)</em></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>EMPLOYEE ENTITLEMENT:</strong> A full-time
employee is entitled to a total of 12 administrative work weeks of
unpaid leave (pro-rated for part-time employees) during any 12-month
period for reasons that are specified in block 3 of the application,
below (see Personnel Letter 630-1, Chapter 8, Section C.) An employee
may not invoke FMLA retroactively for any previous absence. Paid leave
may be substituted for any or all of the periods under FMLA
<em>(Personnel Letter, Chapter 8, Section K.)</em>.</td>
</tr>
<tr class="even">
<td colspan="10">1. Employee’s Name:</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="10">2. If application is for the care of a spouse, son,
daughter, or parent of the employee, indicate the name of the person to
be cared for and the relationship to the employee.</td>
</tr>
<tr class="odd">
<td><strong>Name:</strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><h2 id="relationship">Relationship:</h2></td>
<td colspan="4"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="10"><p>3. Indicate the reason(s) you are applying for leave
under FMLA:</p>
<p> The birth of a son or daughter of the employee and the care of such
son or daughter;</p>
<p> The placement of a son or daughter with the employee for adoption or
foster care;</p>
<p> The care of a spouse, son, daughter, or parent of the employee who
has a serious health condition*; or</p>
<p> A serious health condition* of the employee that makes the employee
unable to perform the essential functions of his</p>
<p>or her position.</p>
<blockquote>
<p><strong>*SERIOUS HEALTH CONDITION:</strong> If this application is
being submitted due to a <em>Serious Health Condition</em> (i.e., of the
employee or the spouse, son, daughter or parent of the employee), the
Certification of Health Care Provider, completed by the health care
provider <strong><u>must</u></strong> accompany this application. The
applicant also needs to complete the last section of the medical
documentation, sign and date the form. The Certification of Health Care
Provider, BPA form 3780.02e, is attached to Chapter 8 as Exhibit 8B and
also provides the definition for a <em>Serious Health Condition</em>
(See Personnel Letter 630-1, Chapter 8, Sections F and L for information
on requests based on <em>Serious Health Conditions</em>). For requests
involving the birth or placement of a son or daughter, the employee must
provide evidence of the birth or placement (adoption or foster care)
that is administratively acceptable to the manager.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="10">4. Number of weeks of leave requested. The 12 week
period begins the first day leave is taken under FMLA and continues for
a 12-month period. (12 weeks in a 12-month period is the maximum for
full-time employees. See Personnel Letter 630-1, Chapter 8, for more
information.)</td>
</tr>
<tr class="even">
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="10">5. Project the type(s) of leave you plan to take for
the period. You may take LWOP, and/or paid leave for which you may be
eligible. See reverse side of this form for eligibility and
documentation requirements for various types of paid leave.</td>
</tr>
<tr class="even">
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="10">6. If you are requesting intermittent leave or a
reduced leave schedule, indicate leave schedule requested. (See
Personnel Letter 630-1, Chapter 8, Section J for more information on
intermittent leave or reduced leave schedules.) NOTE: Request for
intermittent leave or reduced leave schedule must be supported by
acceptable documentation as applicable in section 3 above. Request for
intermittent leave or a reduced leave schedule for birth or placement
(adoption or foster care) is subject to the discretionary approval of
the manager.</td>
</tr>
<tr class="even">
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3">APPLICANT’S SIGNATURE <em>(Request)</em></td>
<td colspan="2">DATE</td>
<td colspan="2">ROUTING</td>
<td colspan="3">TELEPHONE NUMBER</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3">MANAGER’S SIGNATURE (<em>Approval)</em></td>
<td colspan="2">DATE</td>
<td colspan="2">ROUTING</td>
<td colspan="3">TELEPHONE NUMBER</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3">TIER TWO MANAGER’S SIGNATURE <em>(Concurrence)</em></td>
<td colspan="2">DATE</td>
<td colspan="2">ROUTING</td>
<td colspan="3">TELEPHONE NUMBER</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
</tbody>
</table>

FILE CODE: PE-32 RETENTION: CHM= S; OTHERS = S

+-------------+----------------------------------------+--------------+---+
| *BPA F      | **APPLICATION/NOTICE FOR LEAVE UNDER   | *Electronic  |   |
| 3510.04e*   | THE FMLA**                             | Form         |   |
|             |                                        | Approved by* |   |
| *(08-03)    |                                        |              |   |
| Page 2*     |                                        | *CIEP        |   |
|             |                                        | 08/08/2003*  |   |
+-------------+----------------------------------------+--------------+---+
| **PAID      |                                        |              |   |
| LEAVE THAT  |                                        |              |   |
| CAN BE      |                                        |              |   |
| SUBSTITUTED |                                        |              |   |
| FOR LWOP    |                                        |              |   |
| UNDER       |                                        |              |   |
| FMLA**      |                                        |              |   |
|             |                                        |              |   |
| **          |                                        |              |   |
| Eligibility |                                        |              |   |
| and         |                                        |              |   |
| Do          |                                        |              |   |
| cumentation |                                        |              |   |
| Req         |                                        |              |   |
| uirements** |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| Under FMLA, |                                        |              |   |
| employees   |                                        |              |   |
| are         |                                        |              |   |
| entitled to |                                        |              |   |
| take        |                                        |              |   |
| leave-      |                                        |              |   |
| without-pay |                                        |              |   |
| (LWOP), or  |                                        |              |   |
| substitute  |                                        |              |   |
| paid leave  |                                        |              |   |
| for any or  |                                        |              |   |
| all of the  |                                        |              |   |
| time away   |                                        |              |   |
| from work   |                                        |              |   |
| as long as  |                                        |              |   |
| they meet   |                                        |              |   |
| the         |                                        |              |   |
| eligibility |                                        |              |   |
| and         |                                        |              |   |
| do          |                                        |              |   |
| cumentation |                                        |              |   |
| r           |                                        |              |   |
| equirements |                                        |              |   |
| for the     |                                        |              |   |
| paid leave  |                                        |              |   |
| they are    |                                        |              |   |
| requesting. |                                        |              |   |
| (NOTE:      |                                        |              |   |
| Under FMLA, |                                        |              |   |
| an employee |                                        |              |   |
| may choose  |                                        |              |   |
| to take     |                                        |              |   |
| LWOP for    |                                        |              |   |
| the entire  |                                        |              |   |
| 12 week     |                                        |              |   |
| period, and |                                        |              |   |
| cannot be   |                                        |              |   |
| required to |                                        |              |   |
| substitute  |                                        |              |   |
| paid leave  |                                        |              |   |
| for LWOP.)  |                                        |              |   |
| To use paid |                                        |              |   |
| leave       |                                        |              |   |
| instead of  |                                        |              |   |
| LWOP, an    |                                        |              |   |
| employee    |                                        |              |   |
| must        |                                        |              |   |
| request to  |                                        |              |   |
| do so       |                                        |              |   |
| before the  |                                        |              |   |
| payroll is  |                                        |              |   |
| processed   |                                        |              |   |
| for the pay |                                        |              |   |
| period in   |                                        |              |   |
| which the   |                                        |              |   |
| employee is |                                        |              |   |
| absent.     |                                        |              |   |
| Requests to |                                        |              |   |
| re          |                                        |              |   |
| troactively |                                        |              |   |
| substitute  |                                        |              |   |
| paid leave  |                                        |              |   |
| shall not   |                                        |              |   |
| be granted. |                                        |              |   |
| To request  |                                        |              |   |
| LWOP and/or |                                        |              |   |
| various     |                                        |              |   |
| types of    |                                        |              |   |
| paid leave, |                                        |              |   |
| submit an   |                                        |              |   |
| OPM Form 71 |                                        |              |   |
| in advance  |                                        |              |   |
| for each    |                                        |              |   |
| period of   |                                        |              |   |
| leave and   |                                        |              |   |
| for each    |                                        |              |   |
| type of     |                                        |              |   |
| leave       |                                        |              |   |
| requested,  |                                        |              |   |
| indicating  |                                        |              |   |
| FMLA in     |                                        |              |   |
| section 5.  |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| **Annual    |                                        |              |   |
| Leave:**    |                                        |              |   |
| See         |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter 2.  |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| **Advanced  |                                        |              |   |
| Annual      |                                        |              |   |
| Leave:**    |                                        |              |   |
| Submit an   |                                        |              |   |
| OPM Form 71 |                                        |              |   |
| to the      |                                        |              |   |
| manager     |                                        |              |   |
| specifying  |                                        |              |   |
| dates and   |                                        |              |   |
| amount in   |                                        |              |   |
| block 4.    |                                        |              |   |
| The manager |                                        |              |   |
| may approve |                                        |              |   |
| advanced    |                                        |              |   |
| annual      |                                        |              |   |
| leave up to |                                        |              |   |
| the total   |                                        |              |   |
| amount of   |                                        |              |   |
| leave the   |                                        |              |   |
| employee    |                                        |              |   |
| could earn  |                                        |              |   |
| for the     |                                        |              |   |
| remainder   |                                        |              |   |
| of the      |                                        |              |   |
| current     |                                        |              |   |
| leave year; |                                        |              |   |
| [or]{       |                                        |              |   |
| .underline} |                                        |              |   |
| (for        |                                        |              |   |
| temporary   |                                        |              |   |
| employees)  |                                        |              |   |
| for the     |                                        |              |   |
| remainder   |                                        |              |   |
| of their    |                                        |              |   |
| appointment |                                        |              |   |
| or of the   |                                        |              |   |
| current     |                                        |              |   |
| leave year, |                                        |              |   |
| whichever   |                                        |              |   |
| is less.    |                                        |              |   |
| Advanced    |                                        |              |   |
| annual      |                                        |              |   |
| leave       |                                        |              |   |
| cannot be   |                                        |              |   |
| granted if  |                                        |              |   |
| the         |                                        |              |   |
| employee    |                                        |              |   |
| will not    |                                        |              |   |
| return to   |                                        |              |   |
| duty. A     |                                        |              |   |
| copy of the |                                        |              |   |
| advanced    |                                        |              |   |
| leave       |                                        |              |   |
| request     |                                        |              |   |
| must be     |                                        |              |   |
| submitted   |                                        |              |   |
| to Payroll  |                                        |              |   |
| prior to    |                                        |              |   |
| the end of  |                                        |              |   |
| the pay     |                                        |              |   |
| period.     |                                        |              |   |
| (See        |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter 2,  |                                        |              |   |
| Section C.) |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| **Sick      |                                        |              |   |
| Leave:**    |                                        |              |   |
| Except for  |                                        |              |   |
| sick leave  |                                        |              |   |
| taken under |                                        |              |   |
| the Family  |                                        |              |   |
| Friendly    |                                        |              |   |
| Leave Act   |                                        |              |   |
| (see        |                                        |              |   |
| below),     |                                        |              |   |
| generally   |                                        |              |   |
| sick leave  |                                        |              |   |
| may be      |                                        |              |   |
| granted     |                                        |              |   |
| only when   |                                        |              |   |
| an employee |                                        |              |   |
| is: (1)     |                                        |              |   |
| physically  |                                        |              |   |
| in          |                                        |              |   |
| capacitated |                                        |              |   |
| for the     |                                        |              |   |
| performance |                                        |              |   |
| of duties   |                                        |              |   |
| by          |                                        |              |   |
| sickness,   |                                        |              |   |
| injury, or  |                                        |              |   |
| pregnancy   |                                        |              |   |
| or          |                                        |              |   |
| c           |                                        |              |   |
| onfinement; |                                        |              |   |
| (2)         |                                        |              |   |
| receiving   |                                        |              |   |
| medical,    |                                        |              |   |
| dental, or  |                                        |              |   |
| optical     |                                        |              |   |
| examination |                                        |              |   |
| or          |                                        |              |   |
| treatment;  |                                        |              |   |
| and/or (3)  |                                        |              |   |
| receiving   |                                        |              |   |
| therapy or  |                                        |              |   |
| reh         |                                        |              |   |
| abilitation |                                        |              |   |
| treatment   |                                        |              |   |
| associated  |                                        |              |   |
| with mental |                                        |              |   |
| illness or  |                                        |              |   |
| substance   |                                        |              |   |
| abuse or    |                                        |              |   |
| for         |                                        |              |   |
| adoption. A |                                        |              |   |
| manager may |                                        |              |   |
| require     |                                        |              |   |
| that an     |                                        |              |   |
| employee    |                                        |              |   |
| submit a    |                                        |              |   |
| medical     |                                        |              |   |
| statement   |                                        |              |   |
| for each    |                                        |              |   |
| period of   |                                        |              |   |
| sick leave  |                                        |              |   |
| of more     |                                        |              |   |
| than three  |                                        |              |   |
| consecutive |                                        |              |   |
| work days,  |                                        |              |   |
| or for      |                                        |              |   |
| shorter     |                                        |              |   |
| periods if  |                                        |              |   |
| employee is |                                        |              |   |
| on leave    |                                        |              |   |
| control     |                                        |              |   |
| letter.     |                                        |              |   |
| (See        |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter 3.) |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| **Advanced  |                                        |              |   |
| Sick        |                                        |              |   |
| Leave:**    |                                        |              |   |
| Advanced    |                                        |              |   |
| sick leave  |                                        |              |   |
| may be      |                                        |              |   |
| granted to  |                                        |              |   |
| employees   |                                        |              |   |
| in cases of |                                        |              |   |
| illness or  |                                        |              |   |
| disability  |                                        |              |   |
| as follows: |                                        |              |   |
| (1) for     |                                        |              |   |
| permanent,  |                                        |              |   |
| full-time   |                                        |              |   |
| employees,  |                                        |              |   |
| up to 240   |                                        |              |   |
| hours; (2)  |                                        |              |   |
| for         |                                        |              |   |
| permanent,  |                                        |              |   |
| part-time   |                                        |              |   |
| employees,  |                                        |              |   |
| up to a     |                                        |              |   |
| total of 6  |                                        |              |   |
| hours       |                                        |              |   |
| multiplied  |                                        |              |   |
| by the      |                                        |              |   |
| average     |                                        |              |   |
| hours       |                                        |              |   |
| worked per  |                                        |              |   |
| week; or    |                                        |              |   |
| (3) for     |                                        |              |   |
| temporary   |                                        |              |   |
| employees,  |                                        |              |   |
| not more    |                                        |              |   |
| than the    |                                        |              |   |
| amount of   |                                        |              |   |
| sick leave  |                                        |              |   |
| which       |                                        |              |   |
| remains to  |                                        |              |   |
| be earned   |                                        |              |   |
| during      |                                        |              |   |
| their       |                                        |              |   |
| current     |                                        |              |   |
| ap          |                                        |              |   |
| pointments. |                                        |              |   |
| All         |                                        |              |   |
| advanced    |                                        |              |   |
| sick leave  |                                        |              |   |
| requests    |                                        |              |   |
| require a   |                                        |              |   |
| doctor's    |                                        |              |   |
| statement   |                                        |              |   |
| indicating  |                                        |              |   |
| the type of |                                        |              |   |
| illness and |                                        |              |   |
| anticipated |                                        |              |   |
| period of   |                                        |              |   |
| disability. |                                        |              |   |
| The OPM     |                                        |              |   |
| Form 71     |                                        |              |   |
| requires    |                                        |              |   |
| two levels  |                                        |              |   |
| of          |                                        |              |   |
| approval,   |                                        |              |   |
| and is at   |                                        |              |   |
| manager's   |                                        |              |   |
| discretion. |                                        |              |   |
| No employee |                                        |              |   |
| shall be    |                                        |              |   |
| advanced    |                                        |              |   |
| sick leave  |                                        |              |   |
| beyond the  |                                        |              |   |
| ability to  |                                        |              |   |
| repay it. A |                                        |              |   |
| copy of the |                                        |              |   |
| OPM Form 71 |                                        |              |   |
| must be     |                                        |              |   |
| submitted   |                                        |              |   |
| to Payroll  |                                        |              |   |
| before the  |                                        |              |   |
| end of the  |                                        |              |   |
| pay period  |                                        |              |   |
| (the        |                                        |              |   |
| manager     |                                        |              |   |
| should      |                                        |              |   |
| maintain    |                                        |              |   |
| the         |                                        |              |   |
| original    |                                        |              |   |
| and         |                                        |              |   |
| doctor's    |                                        |              |   |
| statement   |                                        |              |   |
| in a        |                                        |              |   |
| secured     |                                        |              |   |
| file). Only |                                        |              |   |
| the initial |                                        |              |   |
| 40 hours of |                                        |              |   |
| sick leave  |                                        |              |   |
| to care for |                                        |              |   |
| a family    |                                        |              |   |
| member may  |                                        |              |   |
| be          |                                        |              |   |
| advanced.   |                                        |              |   |
| (See        |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter 3,  |                                        |              |   |
| Section H.) |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| **Sick      |                                        |              |   |
| Leave Under |                                        |              |   |
| Family      |                                        |              |   |
| Friendly    |                                        |              |   |
| Leave Act   |                                        |              |   |
| (FFLA):**   |                                        |              |   |
| While on    |                                        |              |   |
| FMLA, an    |                                        |              |   |
| employee    |                                        |              |   |
| may         |                                        |              |   |
| substitute  |                                        |              |   |
| their sick  |                                        |              |   |
| leave under |                                        |              |   |
| FFLA        |                                        |              |   |
| instead of  |                                        |              |   |
| LWOP to     |                                        |              |   |
| care for a  |                                        |              |   |
| family      |                                        |              |   |
| member with |                                        |              |   |
| a serious   |                                        |              |   |
| health      |                                        |              |   |
| condition.  |                                        |              |   |
| Up to 40    |                                        |              |   |
| hours of    |                                        |              |   |
| sick leave  |                                        |              |   |
| per leave   |                                        |              |   |
| per year    |                                        |              |   |
| can be used |                                        |              |   |
| without     |                                        |              |   |
| regard to   |                                        |              |   |
| the sick    |                                        |              |   |
| leave       |                                        |              |   |
| balance. If |                                        |              |   |
| the sick    |                                        |              |   |
| leave       |                                        |              |   |
| balance is  |                                        |              |   |
| maintained  |                                        |              |   |
| at 80 hours |                                        |              |   |
| the         |                                        |              |   |
| employee    |                                        |              |   |
| may use up  |                                        |              |   |
| to 480      |                                        |              |   |
| hours of    |                                        |              |   |
| sick leave  |                                        |              |   |
| to care for |                                        |              |   |
| a family    |                                        |              |   |
| member with |                                        |              |   |
| a serious   |                                        |              |   |
| health      |                                        |              |   |
| condition   |                                        |              |   |
| these       |                                        |              |   |
| purposes.   |                                        |              |   |
| For a       |                                        |              |   |
| part-time   |                                        |              |   |
| employee,   |                                        |              |   |
| the number  |                                        |              |   |
| of sick     |                                        |              |   |
| leave hours |                                        |              |   |
| that can be |                                        |              |   |
| used for    |                                        |              |   |
| FFLA        |                                        |              |   |
| purposes is |                                        |              |   |
| prorated to |                                        |              |   |
| the number  |                                        |              |   |
| of hours    |                                        |              |   |
| worked on   |                                        |              |   |
| his/her     |                                        |              |   |
| part-time   |                                        |              |   |
| tour (e.g., |                                        |              |   |
| for         |                                        |              |   |
| employees   |                                        |              |   |
| on a        |                                        |              |   |
| half-time   |                                        |              |   |
| tour, 20    |                                        |              |   |
| hours can   |                                        |              |   |
| be used,    |                                        |              |   |
| etc.).      |                                        |              |   |
| Definition  |                                        |              |   |
| of family   |                                        |              |   |
| member      |                                        |              |   |
| under FFLA  |                                        |              |   |
| is broader  |                                        |              |   |
| than the    |                                        |              |   |
| definition  |                                        |              |   |
| under FMLA. |                                        |              |   |
| (See        |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter 3.) |                                        |              |   |
+-------------+----------------------------------------+--------------+---+
| **Voluntary |                                        |              |   |
| Leave       |                                        |              |   |
| Transfer    |                                        |              |   |
| Program:**  |                                        |              |   |
| An employee |                                        |              |   |
| (donor) may |                                        |              |   |
| donate      |                                        |              |   |
| leave to    |                                        |              |   |
| another     |                                        |              |   |
| employee    |                                        |              |   |
| (recipient) |                                        |              |   |
| when a      |                                        |              |   |
| medical     |                                        |              |   |
| emergency   |                                        |              |   |
| is suffered |                                        |              |   |
| by the      |                                        |              |   |
| recipient   |                                        |              |   |
| or a family |                                        |              |   |
| member of   |                                        |              |   |
| the         |                                        |              |   |
| recipient   |                                        |              |   |
| that is     |                                        |              |   |
| likely to   |                                        |              |   |
| require the |                                        |              |   |
| employee's  |                                        |              |   |
| absence     |                                        |              |   |
| from duty   |                                        |              |   |
| for a       |                                        |              |   |
| prolonged   |                                        |              |   |
| period of   |                                        |              |   |
| time and    |                                        |              |   |
| would       |                                        |              |   |
| result in a |                                        |              |   |
| substantial |                                        |              |   |
| loss of     |                                        |              |   |
| income to   |                                        |              |   |
| the         |                                        |              |   |
| employee.   |                                        |              |   |
| Sp          |                                        |              |   |
| ecifically, |                                        |              |   |
| the         |                                        |              |   |
| employee    |                                        |              |   |
| must be     |                                        |              |   |
| expected to |                                        |              |   |
| be absent   |                                        |              |   |
| from work,  |                                        |              |   |
| without     |                                        |              |   |
| available   |                                        |              |   |
| paid leave, |                                        |              |   |
| for 24      |                                        |              |   |
| hours or    |                                        |              |   |
| more.       |                                        |              |   |
| Recipient   |                                        |              |   |
| must submit |                                        |              |   |
| a           |                                        |              |   |
| physician's |                                        |              |   |
| statement   |                                        |              |   |
| concerning  |                                        |              |   |
| the nature, |                                        |              |   |
| severity,   |                                        |              |   |
| and         |                                        |              |   |
| duration or |                                        |              |   |
| expected    |                                        |              |   |
| duration of |                                        |              |   |
| the medical |                                        |              |   |
| emergency   |                                        |              |   |
| along with  |                                        |              |   |
| completed   |                                        |              |   |
| leave       |                                        |              |   |
| recipient   |                                        |              |   |
| a           |                                        |              |   |
| pplication. |                                        |              |   |
| Application |                                        |              |   |
| is attached |                                        |              |   |
| to          |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter 12  |                                        |              |   |
| (BPA Form   |                                        |              |   |
| 3510.03e,   |                                        |              |   |
| Leave       |                                        |              |   |
| Recipient   |                                        |              |   |
| Ap          |                                        |              |   |
| plication). |                                        |              |   |
| Donations   |                                        |              |   |
| are not     |                                        |              |   |
| guaranteed. |                                        |              |   |
| Manager is  |                                        |              |   |
| not         |                                        |              |   |
| obligated   |                                        |              |   |
| to approve  |                                        |              |   |
| an absence  |                                        |              |   |
| from work   |                                        |              |   |
| [except]{   |                                        |              |   |
| .underline} |                                        |              |   |
| under FMLA. |                                        |              |   |
| (See        |                                        |              |   |
| Personnel   |                                        |              |   |
| Letter      |                                        |              |   |
| 630-1,      |                                        |              |   |
| Chapter     |                                        |              |   |
| 12.)        |                                        |              |   |
+-------------+----------------------------------------+--------------+---+

**Please send a signed copy of this form to the Leave Program Manager,
CHM-1.**