Indiana University Medical Certification For Family Fmla
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2Medical Certification for FAMILY
FMLA - Form #2F
SECTION 1: To be completed by the EMPLOYEE:
Name of Employee (Print):
Employee Contact Information:
(phone)
(email)
My regular work hours/schedule is: ___________ to __________ from ______ a.m./p.m. to ______ a.m./p.m.
(days of the week)
I o authorize o do not authorize (check one) the health care provider identified below to provide the information
requested on this form for the purpose of determining if I qualify for an FMLA leave and for a designated IU human resources
professional to contact the health care provider to authenticate and/or clarify the information, if needed. I understand that if I
do not agree to this authorization, my FMLA leave request could be delayed or denied.
Employee’s Signature:
Date:
An employee who fraudulently obtains FMLA leave will be subject to disciplinary action, up to and including termination.
Name and relationship of family member needing your care:
If family member is your child or same sex domestic partner’s child, provide the date of birth of the child:
Describe the care you will provide to your family member and estimate time needed to provide care:
SECTION 2: To be completed by the HEALTH CARE PROVIDER only:
Instructions to the Health Care Provider: A family member of your patient has indicated a need for leave under the FMLA. Answer fully and
completely ALL applicable parts. Give your best estimate as answers, based on your medical knowledge and experience. “Unknown” or “indeter-
minate” is not sufficient to determine FMLA coverage. Limit your response to the condition for which the patient needs care. Failure to provide
sufficient information may cause the employee’s FMLA request to be delayed or denied.
Part A: Medical Facts:
Approximate date condition began:
Probable duration:
Mark below as applicable:
1.
Was the patient admitted for an overnight stay in the hospital, hospice, or residential medical care facility? o Yes o No
If yes, date(s) of admission:
2.
Date(s) you have treated the patient for this condition:
3.
Will the patient need to have treatment visits at least twice per year due to the condition? o Yes o No
4.
Was medication other than over-the-counter medication, prescribed? o Yes o No
5.
Is your patient reliant on others for transportation for medical care? o Yes o No
6.
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g. physical therapist)? o Yes o No
If yes, state the nature of such treatments, expected duration of treatment, and the name of the other medical provider:
7.
Is the medical condition due to pregnancy complications of the spouse or qualified same sex domestic partner?
o Yes o No If yes, expected delivery date:
FMLA Form 2F
Page 1
UHRS - Rev. 1/10/2011
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