LICENSED EMPLOYEE FAMILY AND MEDICAL LEAVE CERTIFICATION FORM
1. Employee’s Name
2. Patient’s Name (if different from employee)
3. The attached sheet describes what is meant by a “serious health condition” under the Family and Medical Leave Act. Does the patient’s condition, for which the employee is taking FMLA leave, qualify under any of the categories described? If so, please circle the applicable category.
(1) (2) (3) (4) (5) (6)
Or None of the above
4. Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories:
5. a. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient’s present incapacity, i.e. inability to work, attend school or perform other regular activities due to the serious health condition, treatment therefore, or recovery there from, if different):
b. Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in Item 6 below)?
If yes, give the probable duration:
c. If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity:
6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments:
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 of and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:
b. If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the treatments:
c. 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):
7. a. If 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 kids?
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 employee or the employer should supply you with information about the essential job functions)?
If yes, please lest the essential functions the employee is unable to perform.
c. If neither, a. nor b. applies, is it necessary for the employee to be absent from work for treatment?
8. a. If leave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation?
b. If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in the patient’s recovery?
c. If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need:
Signature of Health Care Provider Type of Practice
Address Telephone Number
To be completed by the employee needing family leave to care for a family member.
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
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 incapacity or subsequent treatment in connection with or consequent to such inpatient care.
2. Absence Plus Treatment – A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves:
a. treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision of a health care provider or by a provider of health care services (e.g. physical therapist) under the orders of, or on referral by, a health care provider; or
b. treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.
3. Pregnancy – Any period of incapacity due to pregnancy or for prenatal care.
4. Chronic Conditions Requiring Treatments – A chronic condition which:
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 period of incapacity (e.g. asthma, diabetes, epilepsy, etc.)
5. Permanent/Long-term Conditions Requiring Supervision – A period of incapacity 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. Examples include 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 therefrom) 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 incapacity 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) and kidney disease (dialysis).
UPLOAD FORM