(Family and Medical Leave Act of 1993 as amended)
SECTION I. For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your medical provider. The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave for the employee’s serious health condition to submit a timely and complete certification providing sufficient facts to support the request for leave. Your response is required to obtain or retain the benefit of FMLA- protected leave. Failure to do so may result in a denial of your FMLA request. You have 15 calendar days to return this form to your supervisor.
Your name:___________________________________________________________________________________
First Middle Last
Your department/division:_______________________________________________________________________
Your job title:____________________________ Your regular work schedule:___________________________
Your supervisor:_______________________________________________________________________________
Your essential job functions:______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Check if job description is attached:______
SECTION II. For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FLMA coverage. Limit your responses to the condition for which the employee is seeking leave. Page 4 provides space for additional information, should you need it. Please be sure to sign the form on the last page.
Provider’s name and business address: _____________________________________________________________
Type of practice/Medical speciality:________________________________________________________________
Telephone (____) _________________________ Fax: (____)________________________________________
PART A. MEDICAL FACTS
1. Approximate date condition commenced:_______________________________________________________
Probable duration of condition:_______________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
____ Yes ____ No If yes, dates of admission:
________________________________________________________________________________________
Date(s) you treated the patient for condition:
________________________________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition? ____ Yes ____ No
Was medication, other than over-the-counter medication, prescribed? ____ Yes ____ No
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
____ Yes ____ No If so, state the nature of such treatments and expected duration of treatment:
________________________________________________________________________________________
________________________________________________________________________________________
2. Is the medical condition pregnancy? ____ Yes ____ No If yes, expected delivery date:__________________
3. Use the information provided in Section I to answer this question.
Is the employee unable to perform any of his/her job functions due to the condition: ____ Yes ____ No
If so, identify the job functions the employee is unable to perform:
________________________________________________________________________________________
4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PART B. AMOUNT OF LEAVE NEEDED
5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? ____ Yes ____ No
If so, estimate the beginning and ending dates for the period of incapacity:______________________________
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee’s medical condition: ____ Yes ____ No
If so, are the treatments or the reduced number of hours of work medically necessary? ____ Yes ____ No
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period.
_________________________________________________________________________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
__________ hour(s) per day; _________ days per week from _______________ through _________________
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? ____ Yes ____ No. If yes, explain:
Is it medically necessary for the employee to be absent from work during the flare-ups? _____Yes _____No
If yes, explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2days):
Frequency: __________ times per ________ week(s) month(s) ___________
Duration: ________ hours or _______ day(s) per episode
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
________________________________________ __________________________________________
Signature of Health Care Provider Date