Caregiver's Leave Application

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Please find your Agency Code using the list below. You will need to enter your agency code to complete the next step in the form. Use all CAPS when entering your agency code in the next field.

CODE Agency Name

DOA-------------Department of Agriculture

BOE-------------Board of Education

BNL-------------Board of Nurse Licensure

BSCM------------Bureau of School Construction & Maintenance

BCTE------------Career and Technical Education Board

CCC-------------Casino Control Commission

OCB-------------Office of Collective Bargaining

BOC-------------Corrections Bureau

EDA-------------Economic Development Authority

BER-------------Bureau of Economic Research

DOE-------------Department of Education

ES--------------Election System

EO--------------Energy Office

DOF-------------Department of Finance

FEMS------------Fire Service/EMS

GERS------------Government Employees' Retirement System

OOG-------------Governor's Office

DOH-------------Department of Health

VIHA------------VI Housing Authority

VIHFA------------VI Housing Finance Authority

DHS-------------Department of Human Services

BIT-------------Bureau of Information Technology

VIIG------------Inspector General - V.I.

BIR-------------Bureau of Internal Revenue

JFL-------------Juan Luis Hospital

JUD-------------Judicial Branch

DOJ-------------Department of Justice

DOL-------------Department of Labor

LEPC------------Law Enforcement Planning Commission

LEG-------------Virgin Islands Legislature

DLCA------------Department of Licensing and Consumer Affairs

LGO-------------Lieutenant Governor's Office

VIL-------------VI Lottery

MBA-------------Magens Bay Authority

OMB-------------Office of Management and Budget

BMV-------------Bureau of Motor Vehicles

OTAG------------National Guard

DOP-------------Division of Personnel

DPNR------------Department of Planning and Natural Resources

VIPD------------VI Police Department

VIPA------------Port Authority

DPP-------------Department of Property and Procurement

WTJX------------Public Broadcasting System

OTPD------------Office of Public Defender - Territorial

PERB------------Public Employees Relations Board

PFA-------------Public Finance Authority

PSC-------------Public Services Commission

DPW-------------Department of Public Works

SRMC------------Schneider Regional Medical Center

SPR-------------Department of Sports, Parks and Recreation

TCC-------------Taxicab Commission

DOT-------------Department of Tourism

UVI-------------University of the Virgin Islands

VA--------------Office of Veterans Affairs

VINGN-----------viNGN

VITEMA----------VITEMA

VIWMA-----------VI Waste Management Authority

WAPA-----------Water and Power Authority

WICO------------West Indian Company
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Department/Agency Code* This field is required.Please type your Department/Agency code to begin your submission. (USE ALL CAPS)
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Please Read

Before you move on, gather the required documents listed in the sections below called 1)Seriously Ill Spouse, Child, Parent, or Legal Dependent, 2)Older Adult, and 3) Dependent Adult. Having everything ready will make the online application process much smoother. Thank you.

Caregiver's Leave applies to all full-time employees of the Government of the Virgin Islands, including employees of all branches, independent boards, commissions, agencies, autonomous and semi-autonomous agencies, and instrumentalities of the Government of the Virgin Islands.

Verification of eligibility for Caregiver's Leave must be completed for each qualifying individual needing care. Once established verification is valid for up to 12 months. Eligible Employees are entitled to up to four hours of administrative leave per month, each calendar year. Caregiver's Leave does not roll over and must be used in the month it is accrued. Caregiver's Leave may be used in increments, not to exceed total allowable in any given month, consistent with agency/GVI timekeeping practices.

Employees shall notify their immediate supervisor of the need to use Caregiver’s Leave in advance where practical, or as soon as reasonably possible (not more than 48 hours after the start of the absence).

QUALIFYING CATEGORIES AND REQUIRED DOCUMENTATION

1) Seriously Ill Spouse, Child, Parent, or Legal Dependent

Employees must provide documentation sufficient to establish:

a) That the qualifying individual to be cared for has a serious illness requiring caregiver involvement;

b) The eligible relationship of caregiver to the qualifying individual; and

c) That the employee is the caregiver of the qualifying individual.

Required documentation:

Caregiver's Leave Medical Certification confirming need for caregiving (no diagnosis disclosure required);

Legal documentation establishing eligible relationship and/or dependent status (ie. marriage certificate, birth certificate, court order);

Employee certification of caregiver responsibility.

2) Older Adult

Employees must provide documentation sufficient to establish:

a) That the individual to be cared for is an older adult.

b) That the employee has been entrusted with or assumed responsibility for providing or coordinating care for the older adult.

Required documentation:

Proof of age (i.e., government-issued ID) of the older adult;

Caregiver's Leave Employee Certification of assumption of responsibility;

3) Dependent Adult

Employees must provide documentation sufficient to establish:

a) That the individual to be cared for is a dependent adult;

b) That the employee has been entrusted with or assumed responsibility for providing or coordinating care for the dependent adult.

Required documentation:

Legal documentation establishing dependent adult status;

Employee certification of assumption of responsibility

4) Employee Certification

In all cases, a completed employee certification shall be required and shall confirm the employee's role as a caregiver or person responsible for or assuming care.
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Agency Name* This field is required.
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Full Name* This field is required.
First Name
Last Name
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Employee ID Number* This field is required.
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Employee Email* This field is required.
example@example.com
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District* This field is required.
Please Select
Please Select
St. Croix
St. Thomas/St. John
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Immediate Supervisor* This field is required.
First Name
Last Name
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Immediate Supervisor GVI Email* This field is required.
example@example.com
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Human Resources Officer GVI Email* This field is required.This is the email address of your HR Officer who will review your submission. You cannot edit this field.
example@example.com
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Caregiver Defined

An employee who has primary responsibility for providing or coordinating essential non-paid assistance, care, or support to a qualifying individual who, due to age, illness, disability, or a medical or behavioral health condition, requires help with activities of daily living, medical care, supervision, or transportation to and from appointments or supportive services, regardless of whether other individuals also provide support. This definition does not require cohabitation.
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Older Adult Defined

Any person residing in this United States Virgin Islands who is 60 years of age or older.
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Dependent Adult Defined

Any person between the ages of 18 and 59 years who resides in the United States Virgin Islands and has physical, mental, or emotional developmental disabilities that substantially impair the person’s ability to carry out normal activities and protect the person’s own rights and interests.
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Employee Certification* This field is required.Upload Completed Employee Certification Form
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Caregiver Eligibility Category* This field is required.
Please Select
Please Select
1. The primary caregiver of a seriously ill spouse, child, parent, or legal dependent.
2. Entrusted with or have assumed responsibility for the care of an Older Adult. "Any person who resides in the US Virgin Islands who is 60 years of age or older".
3. Entrusted with or have assumed responsibility for the care of a Dependent Adult. "Any person between the ages of 18 and 59 years who resides in the US Virgin Islands and has physical, mental, or emotional developmental disabilities that substantially impair the person’s ability to carry out normal activities and protect the person’s own rights and interests".
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Name of person to be cared for* This field is required.
First Name
Last Name
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Medical Certification* This field is required.Upload Medical Certification Form
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Verification of Eligible Relationship (Spouse, Child, Parent, or Legal Dependent).* This field is required.Upload Marriage Certificate, Birth Certificate, or Legal Document proving dependency.
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Verification of Older Adult (60+)* This field is required.Upload Government Issued ID of older adult.
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Max. file size: 10.6MB
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Verification of Dependent AdultUpload documentation proving legal dependency.
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The information I have provided in this form is true, complete, and accurate to the best of my knowledge and belief.* This field is required.
I attest to the statement above
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Enforcement & Oversight

The Division of Personnel shall oversee compliance and issue guidance as needed. Misuse or misrepresentation may result in denial of leave, recovery of improperly paid leave, disciplinary action, and/or referral for further investigation consistent with applicable personnel rules and the GVI ethical code of conduct.

Failure of agency personnel to follow the requirements under this policy may result in disciplinary action.

Any questions regarding interpretation of this policy shall be directed to the Director of the Division of Personnel.
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Applicant Signature /Employee Name/* This field is required./Jane Doe/
Should be Empty: