Medical Certification Employees Own Serious Health Condition Form


NALC Form 1 - Family and Medical Leave Act
Health Care Provider: Please complete this form in order to aid the employer in making its FMLA determination.
Medical Certification—Employee’s Own Serious Health Condition
The employee’s health care provider must complete this form when an employee requests FMLA leave and medical documentation
is required (see ELM Sections 512.41, 513.36 and 515.5). The employee must also complete and submit a PS Form 3971 -
Request for or Notification of Absence.
Employee: Return the completed form to the appropriate FMLA administration HRSSC address or fax (see attached sheet) and keep a copy
for your own records.
Employee’s Name: ______________________________________________________________________________________________________
EIN: __________________________________________ FMLA Case # (if known): __________________________________________________
1. Medical facts:
The back (p. 2) of this form contains sets of medical facts that the FMLA uses to define a serious health condition. Does the
employee’s health condition
match any of these sets of medical facts? If so, please check the applicable set.
❒ 1. Hospitalization ❒ 2. Absence plus Treatment ❒ 3. Pregnancy ❒ 4. Chronic Condition ❒ 5. Permanent/Long-term ❒ 6. Multiple Treatments ❒ None of these
2. Description of medical facts:
Please describe the medical facts that correspond to the set of medical facts checked above. Such medical
facts may include symptoms, hospitalization, doctor visits, whether medicine has been prescribed and any regimen of continuing treatment. A
specific diagnosis or prognosis is not required.
3. Duration of the condition
(Be as specific as you can; terms such as “lifetime,” “unknown” or “indeterminate” should be used only when they
reflect your best medical judgment.)
a. Approximate date condition commenced: _____________________ Probable duration of condition: _____________________
4. Is the employee able to perform the essential functions of his or her position?
If no, please describe the employee’s restrictions and their duration:
Will the employee require leave that is medically necessary on an intermittent or reduced schedule basis for planned medical treatment of the
employee’s serious health condition, including pregnancy? ❒ Yes
❒ No
If yes, please provide an estimate of the dates and duration of such treatment(s) and any period(s) of recovery.
Dates: ____________________________________ Duration:
_____ hour(s) or
_____ day(s) per episode.
Period of Recovery: ________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
_____ hour(s) per day; _____ day(s) per week from ___________ through __________.
Will the employee require leave that is medically necessary on an intermittent or reduced schedule basis for the employee’s serious health condi-
❒ Yes
❒ No
tion, including pregnancy, that may result in unforeseeable episodes of incapacity
(e.g. flare-ups)?
If yes, please provide an estimate of the frequency and duration of such episodes of incapacity (e.g. 3 episodes every 2 months lasting 1-2 days):
Frequency: _____ times per _____ week(s) _____ month(s) Duration: _____ hours or _____ day(s) per episode
Health Care Provider Signature: ____________________________________________________________ Date:__________________________
Print Name: __________________________________________ _________________________________ Phone: (______)_________________
Medical Practice/Specialty: _______________________________________________________________ FAX: ___________________________
Address: _____________________________________________________________________________________________________________
Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave.
Flare-ups or other unforeseeable leave in the case of chronic conditions or pregnancy need not require treatment by a health care provider.
NALC Form 1 (page 1 of 2) - 5/24/2013


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