Fillable Purdue University Fmla Medical Certification Form printable pdf download

Purdue University

Human Resources

Revised 7/13

PERNR:

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Org. Unit:

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FMLA Medical Certification Form

A complete medical certification is required to determine whether your health condition, or the health condition of your Spouse*, Son

or Daughter or Parent, qualifies for leave under FMLA regulations.

Instructions to Employee: Complete Sections I and II. If you are requesting leave to care for your Spouse*, Son, Daughter or

Parent who has a Serious Health Condition, also complete Section III. Your health care provider or your family member’s health

care provider must complete Sections IV through IX. It is your responsibility to ensure that the health care provider

completes this form and returns it to the appropriate address within 15 calendar days.

Instructions to Health Care Provider: Your patient or a family member of your patient has requested a Family and Medical Leave.

In order for us to verify that this qualifies under the FMLA, please complete Sections IV through IX of this form, and return it within 15

calendar days of receipt to the appropriate contact listed below:

WEST LAFAYETTE EMPLOYEES:

REGIONAL EMPLOYEES:

Purdue University

Indiana University Purdue

Purdue University

Calumet

University Fort Wayne

Human Resources-

Human Resources

Human Resources - Service Center

Human Resources

Schneider Avenue Building Rm 1005

2101 Coliseum Boulevard East

Service Center

(HRSC)

2200 169th Street

Fort Wayne, IN 46805

Freehafer Hall

Hammond, IN 46323-2094

Phone: (260) 481-6684

Phone: (219) 989-2251

FAX:

(260) 481-4164

401 S. Grant Street

FAX:

(219) 989-2185

West Lafayette, IN 47907-2024

Phone: (765)496-6269, 494-1533,

Phone: (765) 494-2222

Purdue University

Or 494-1310

North Central

Human Resources

FAX: (765) 494-6720

1401 South U.S. Highway 421

Westville, IN 46391

Phone: (219) 785-5301

FAX:

(219) 785-5540

To be Completed By Employee

Section I – Patient Information (Printed)

Employee’s Name:

Patient’s Name:

Relationship to Employee (if son or daughter, list date of birth):

Section II – Employee Signature

I permit Purdue University Human Resources or its designated Health Care Provider/third party administrator to contact my

Health Care Provider or my family member’s Health Care Provider for purposes of obtaining clarifying information and

authenticity of the medical certification, if necessary.

_______________________________________________

________________________________________

Employee Signature

Date

Section III – Care for Family Member (Printed)

State the care you will provide for your family member (if designated above).

___________________________________________________________________________________________________________

*While the FMLA definition of “spouse” does not include same sex domestic partners, same sex domestic partners will be deemed “spouses” for purposes of this policy,

pursuant to the Board of Trustees’ September 2002 resolution which granted benefits to same sex domestic partners.

Purdue University Fmla Medical Certification Form

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