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1. Employee’s Name:
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2. Patient’s Name (if different from employee):
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3. The attached sheet describes what is meant by a “serious health condition” under the Family and Medical Leave Act. Check the appropriate category under which the patient’s condition1 qualifies:
(1)____ (2)____ (3)____ (4)____ (5)____ (6)____ none of the above____ |
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4. Describe the medical facts that support your certification, including a brief statement as to how the medical facts meet the criteria checked above:
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5. a. State the approximate date the condition commenced and the probable duration of the condition (state the probable duration of the patient’s present incapacity2 if different):
b. Will it be necessary for the employee to work only intermittently or to work on a less than full schedule as a result of the condition (including the treatment described in #6 below)?
yes no If yes, give the probable duration: c. If the condition is a chronic condition (#4 under section III) or pregnancy, state whether the patient is presently incapacitated2 and the likely duration and frequency of episodes of incapacity2:
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1Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave. 2Incapacity for purposes of FMLA means the inability to work, attend school, or perform other regular daily activities due to the serious health condition, treatment for, or recovery from. |
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6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments:
b. If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery, if any:
c. If any of these treatments will be provided by another provider or health service (e.g., physical therapist) please state the nature of treatments:
d. If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g., prescription drugs, physical therapy requiring special equipment)
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7. a. If a medical leave is required for the employee’s absence from work because of the employee’s own condition (including absences due to pregnancy or a chronic condition) is the employee unable to perform work of any kind? yes no
b. If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee’s job (the employer or employee should supply you with information about the essential job functions)? yes no If yes, please list the essential job functions the employee is unable to perform: c. If neither of the above applies, is it necessary for the employee to be absent from work for treatment? yes no |
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8. a. If leave is required for care for an employee’s family member with a serious health condition, does the patient require assistance for basic medical or personal needs, safety or for transportation? yes no
b. If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in the patient’s recovery? yes no
c. If the patient will need care only intermittently or on a part-time basis, indicate the probable duration of this need:
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_____________________________________ _________________________________ Signature of Health Care Provider Type of Practice
_____________________________________ _________________________________ Address Telephone Number
_____________________________________ _________________________________ City, State, Zip Code Date |
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TO BE COMPLETED BY EMPLOYEE NEEDING FAMILY LEAVE TO CARE FOR A FAMILY MEMBER |
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State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule:
______________________________________ __________________________ Employee Signature Date |
SERIOUS HEALTH CONDITION
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A
“Serious Health Condition” means an illness, injury, impairment or
physical or mental condition that involves one of the following:
1. Hospital Care inpatient care (i.e., an overnight stay) in a hospital, hospice or residential medical care facility, including any period of incapacity2 or subsequent treatment in connection with or consequent to such inpatient care. 2. Absence Plus Treatment a period of incapacity2 of more than three consecutive calendar days (including any subsequent treatment or period of incapacity2 relating to the same condition), that also involves: (a) treatment3 two or more times by a health care provider, by a nurse of physician’s assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or (b) treatment by a health care provider on at least one occasion that results in a regimen of continuing treatment4 under the supervision of the health care provider. 3. Pregnancy any period of incapacity2 due to pregnancy, or for prenatal care 4. Chronic Conditions Requiring Treatments a chronic condition that: (a) requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under direct supervision of a health care provider (b) continues over an extended period of time (including recurring episodes of a single underlying condition); and (c) may cause episodic rather than a continuing period of incapacity2 (e.g., asthma, diabetes, epilepsy, etc.) 5. Permanent/Long-term Conditions Requiring Supervision a period of incapacity2 which is permanent or long-term due to a condition for which treatment may not be effective; the employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider (e.g., Alzheimer’s, a severe stroke or the terminal stages of a disease) 6. Multiple Treatments (Non-Chronic Conditions) any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity2 of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis)
____ ____________________________ 2incapacity for purposes of FMLA means the inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for, or recovery from 3treatment includes examinations to determine if a serious health condition exists and evaluations of the condition; treatment does not include routine physical examinations, eye examinations or dental examinations 4a regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition; a regimen of treatment does not include the taking of over-the-counter medications such as aspirin, antihistamines or salves; or bed-rest, drinking fluids, exercise and other similar activities that can be initiated without a visit to a health care provider |