Certification For Injury Or Illness Of Covered Service Member For Military/family Leave (Fmla) Form Page 2
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NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to
take leave to care for a covered family member with a “serious health condition” under §825.113
of the FMLA. If such leave is requested, you may be required to complete DOL FORM WH-380
or an employer-provided form seeking the same information.)
(2)
Was the condition for which the Covered Servicemember is being treated incurred in the line of duty on
active duty in the Armed Forces? ____ Yes ____ No
(3)
Approximate date condition commenced:
(4)
Probable duration of condition and/or need for care:
(5)
Is the covered servicemember undergoing medical treatment, recuperation, or therapy? ____ Yes ____ No
If yes, please describe medical treatment, recuperation or therapy:
COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1)
Will the covered servicemember need care for a single continuous period of time, including any time for
treatment and recovery? ____ Yes ____ No
If yes, estimate the beginning and ending dates for this period of time:
(2)
Will the covered servicemember require periodic follow-up treatment appointments?
____ Yes ____ No
If yes, estimate the treatment schedule:
(3)
Is there a medical necessity for the covered servicemember to have periodic care for these follow-up
treatment appointments? ____ Yes ____ No
(4)
Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled
follow-up treatment appointments (e.g., episodic flare-ups of medical condition)? ____ Yes ____ No
If yes, please estimate the frequency and duration of the periodic care:
Signature of Health Care Provider
Date
Health Care Provider’s Name and Business Address:___________________________________________________
Type of Practice/Medical Specialty:
Telephone: (
) _______________ Fax: (
) _______________ Email:
Please indicate whether you are either: ____ a DOD health care provider; ____ a VA health care provider; ___ a
DOD TRICARE network authorized private health care provider; or ___ a DOD non-network TRICARE authorized
private health care provider.
P
:
L E A SE R E T UR N F UL L Y C OM PL E T E D F OR M T O
Office of Human Resources
Fashion Institute of Technology
th
th
Street, 11
Floor
236 W. 27
New York, NY 10001-5992
or Confidential Fax: (212) 217-3651
Rev. 5/09
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Parent category: Legal