Fillable Indiana University Medical Certification For Employee Fmla (Page 2 of 2) in pdf

Is the medical condition due to complications of pregnancy? o Yes o No If yes, expected delivery date:

Comments:

Answer the questions if the essential functions of the employee’s job are attached.

Is the employee unable to perform any of his/her essential job functions due to the condition? o Yes o No

If yes, identify the essential job functions the employee is unable to perform:

Describe relevant facts such as symptoms, diagnosis, or any regimen of continuing treatment, related to the condition for

which the employee needs leave:

Part B: Amount of Leave Needed:

Will the employee be incapacitated for a single continuous period of time due to his/her medical condition including any

time for treatment and recovery? o Yes o No If yes, estimate the beginning and ending dates for the continuous period

of incapacity:

Will it be medically necessary for the employee to have follow-up treatments? o Yes o No

If applicable, estimate times needed for treatments, appointments, and recovery:

Is it medically necessary for the employee to work part-time or a reduced work schedule? If yes, please estimate the:

____ Hour(s) per day off work ____ Day(s) per week off work

From (date)________________ through (date)________________

Will the condition cause episodic flare-ups which prevent the employee from performing his/her job functions?

o Yes o No

Is it medically necessary for the employee to be absent from work during the flare-ups? o Yes o No If yes, explain:

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups

and the duration of incapacity that the patient may have (e.g. an episode every 3 months lasting 1 day):

Frequency: ______ # times per o week or o month

For: _____ # hours or _____# day(s) per episode

From: ___________ (date) to ___________ (date)

GINA Notification to Health Care Providers: 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 employees or their family members. In order 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.

Signature of Health Care Provider:

Date:

Printed name of Health Care Provider:

Type of Practice/Medical specialty:

Contact information of Health Care Provider:

(Address)

(Phone number)

(Fax)

(Email address)

FMLA Form 2E

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