Fmla/cfra Med-Cert Certification Of Health printable pdf download

Fmla/cfra Med-Cert Certification Of Health

APPENDIX C

FMLA/CFRA MED-CERT

Certification of Health

U. S. Department of Labor

Employment Standards Administration

Care Provider

Wage and Hour Division

(Family and Medical Leave Act of 1993)

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

qualify under any of the categories described? If so, please check

the applicable category.

(1)

(2)

(3)

(4)

(5)

(6)

or None of the Above

4. 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 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 for treatment described in Item 5 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

5. 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 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, please indicate

the estimated number of doctor’s visits, and/or estimated duration of medical treatment, either by the health care

practitioner or another provider of health services, upon referral from the health care provider.

Here and elsewhere on this form, the information sought relates only to the condition for which the employee is

taking FMLA leave.

“Incapacity” for purposes of FMLA is defined to mean inability to work, attend school, or perform other regular

daily activities due to the serious health condition, treatment therefore, or recovery therefrom.

Fmla/cfra Med-Cert Certification Of Health