(Family and Medical Leave Act of 1993)
SECTION I. For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your family member or his/her medical provider. The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave to care for a covered family member with a 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:_______________________________________________________________________________
Name of family member for whom you will provide care: ______________________________________________
First Middle Last
Relationship of family member to you:______________________________________________________________
If family member is your son or daughter, date of birth: ____________________________________________
Describe care you will provide to your family member and estimate leave needed to provide care:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________ __________________________________________
Employee Signature Date
SECTION II. For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. 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 patient needs 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:_______________________________________________________
Probably duration of condition:_______________________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
____Yes ____No If so, dates of admission: _____________________________________________________
Date(s) you treated the patient for condition: _____________________________________________________
Was medication, other than over-the-counter medication, prescribed? ____Yes ____No
Will the patient need to have treatment vistis at least twice per year due to the condition? ____Yes ____No
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
____Yes ____No If yes, 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. Describe other relevant medical facts, if any, related to the condition for which the patient needs 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 CARE NEEDED: When answering these questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs or the provision of physical or psychological care.
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? ____Yes ____No.
Estimate the beginning and ending dates for the period of incapacity:__________________________________
During this time, will the patient need care: ____Yes ____No.
Explain the care needed by the patient and why such care is medically necessary:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
5. Will the patient require follow-up treatments, including any time for recovery? ____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:
_________________________________________________________________________________________
Explain the care needed by the patient, and why such care is medically necessary:________________________
_________________________________________________________________________________________
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?
____Yes ____No
Estimate the hours the patient needs care on an intermittent basis, if any:
______ hour(s) per day; ______days per week form __________________through ______________________
Explain the care needed by the patient, and why such care is medically necessary:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities? ____Yes ____No
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 1-2 days):
Frequency: ______times per ______week(s)______month(s).
Duration: ______hours or ______day(s) per episode.
Does the patient need care during these flare-ups? ______Yes _____No
Explain the care needed by the patient, and why such care is medically necessary:________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
_____________________________________________________ ___________________________________
Signature of Health Care Provider Date
MCPR 2008