§ 1–612.07. Application for withdrawal.

(a) An application for withdrawal of leave from the PFML Bank shall proceed as follows:

(1) An eligible employee who expects to experience an absence of 10 or more workdays due to a qualifying medical leave event or qualifying family leave event may make a written application to the PFML Bank Administrator to become a leave recipient.

(2) If the employee is not capable of making an application on the employee's own behalf, the employee may designate a representative to make a written application on the employee's behalf.

(b) The application shall include at least the following:

(1) The anticipated duration of the prolonged absence;

(2) The name, position title, and grade of the proposed leave recipient;

(3) The amount of leave requested;

(4) A declaration, signed under penalty of perjury, by the proposed leave recipient or the proposed leave recipient's designated representative attesting to the fact that the employee is experiencing a qualifying medical leave event or qualifying family leave event; and

(5)(A) Certification from a physician or other licensed healthcare professional that the proposed leave recipient, in the case of qualifying medical leave, or the proposed leave recipient's immediate family member, in the case of qualifying family leave, has experienced a serious health condition and the anticipated duration of the condition.

(B) The International Classification of Diseases, Tenth Revision (ICD-10), or subsequent revisions by the World Health Organization to the International Classification of Diseases, along with any health care provider or caretaker assessments, shall be used to determine the appropriate length of qualifying family leave to which an eligible employee is entitled, based on the serious health condition of the eligible employee's family member, or the appropriate length of qualifying medical leave to which an eligible employee is entitled, based on the serious health condition of the eligible employee.