Indiana University Medical Certification For Employee Fmla
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2Medical Certification for EMPLOYEE
FMLA - Form #2E
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.
SECTION 2: To be completed by the EMPLOYER:
•
A completed Form 3, Intent to Return and Fitness for Duty/Medical Release, will be required prior to the employee’s
return to work, o Yes o No
•
If yes, essential job functions are attached (REQUIRED for Serious Health Conditions)
o Yes, it is attached
SECTION 3: To be completed by the HEALTH CARE PROVIDER only:
Instructions to the Health Care Provider: Your patient has indicated a need for leave under the FMLA. Answer fully and
completely ALL applicable parts. Your answer should be your best estimate based on your medical knowledge and experience.
“Unknown” or “indeterminate” is not sufficient to determine FMLA coverage. Limit your responses to the condition for which the
employee is seeking leave. 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.
Dates 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.
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 other medical
provider:
FMLA Form 2E
Page 1
UHRS - Rev. 1/10/2011
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