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To Employee - Complete the following information on every page

University of Washington

(not for HMC or UWMC staff)

Family and Medical Leave

Employee Name:

Certification of Health Care Provider

Department:

for Family Member’s Serious Health

Employee Phone:

Condition

Employee Email:

Human Resources (not for medical centers staff)

Return to:

To Employee: Complete Part 1 and arrange for your family member’s

Campus HR Operations

health care provider to complete Part 2. Return the completed form

Roosevelt Commons West

as soon as possible but no later than 15 calendar days after the

Box 354963

date you receive it. Return to the person or location indicated in the

4300 Roosevelt Ave NE

“Return to” space at the right. Contact this person or office if you

Seattle, WA 98195-4963

believe that you will not be able to return the completed form within the

Voice: (206) 543-2354 Fax: (206) 685-0636

specified time period.

PART 1 – To Be Completed by Employee (Please Print)

Supervisor’s name

Supervisor’s title

Supervisor’s phone

Supervisor’s email

Family member’s name

Family member’s relationship to you

Parent

Child

Spouse

Domestic Partner

Brother/Sister

Grandchild

Grandparent

If a child, the child’s date of birth:

Describe type of care you will provide to your family member

I am requesting time off work

Yes

I am requesting a reduced work schedule as follows

Yes

If Yes: From (date) _______________ to (date) ______________

If Yes: _____ hours/day for ________ days/week until (date) _____________

I am requesting an intermittent work schedule

Yes

If yes, describe requested schedule:

Employee Signature ___________________________________________________________ Date ______________________

PART 2 – Medical Facts: To Be Completed by Family Member’s Health Care Provider

Our employee is requesting leave from work or a modified work schedule under the FMLA to care for a family member who is your

patient. Please provide the information requested below so that we can process our employee’s leave request. Only provide

information regarding the condition(s) that relate to your patient’s need for care from another person. The Genetic Information

Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of

an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide

any genetic information when responding to this request for medical information. 'Genetic information' as defined by GINA, includes an individual's

family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought

or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by

an individual or family member receiving assistive reproductive services.

For Pregnancy-Related Incapacity

Expected date of delivery for your patient

Expected dates of your patient’s physical incapacity due to pregnancy and delivery (not parental leave)

From (date) ______________ to (date) ______________

Are there any factors that you currently know of that are likely to extend the length of pregnancy-related incapacity?

Yes

If yes, please explain:

April 30, 2015