Family And Medical Leave Certification Of Health Care Provider For Personal Serious Health Condition - University Of Washington

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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 Personal Serious Health Condition
Employee Phone:
Human Resources
Employee Email:
Return to:
To Employee: Complete Part 1 and arrange for your health care provider
Campus HR Operations
to complete Part 2. Return the completed form as soon as possible,
Roosevelt Commons West
but no later than 15 calendar days after the date you receive it.
Box 354963
Return to the person or location indicated in the “Return to” space at the
4300 Roosevelt Ave NE
right. Contact this person or office if you believe that you will not be able to
Seattle, WA 98195-4963
return the completed form within the specified time period.
Voice: (206) 543-2354 Fax: (206) 685-0636
PART 1 – To Be Completed by Employee (Please Print)
Supervisor’s name
Supervisor’s title
Supervisor’s phone
Supervisor’s email
I am requesting time off work
No
Yes
I am requesting a reduced work schedule as follows
No
Yes
From (date) ____________ to (date) ____________
_____ hours/day for ________ days/week until (date) _____________
I am requesting an intermittent work schedule
No
Yes
If yes, describe requested schedule:
Employee Signature ___________________________________________________________ Date ______________________
PART 2 – Medical Facts: To Be Completed by Health Care Provider
Our employee is requesting leave from work and/or a modified work schedule under the FMLA for a health condition. 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 our employee’s request to take leave or adopt a modified work schedule. Several of
the following questions ask about the frequency or duration of a condition or treatment. We know that health conditions can
vary or change over time, so please provide your best estimate in response to these questions, being as specific as you can.
Using terms such as “lifetime,” “unknown,” or “indeterminate” may not be specific enough for us to determine leave eligibility
for our employee under the Family and Medical Leave Act.
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.
Describe the medical facts related to the condition(s) that require our employee to be off work and/or to work a reduced or intermittent work schedule
(medical facts may include symptoms, diagnosis, or any plan for continuing treatment or therapy)
Approximate date condition(s) began
Probable duration of condition(s) (days, weeks, months)
Was your patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No
Yes
If yes, dates of admission: _____________________________________________________
Will your patient need to have treatment visits at least twice per year due to the condition?
No
Yes
Was medication, other than over-the-counter medication, prescribed?
No
Yes

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