Nalc Form 1 - Medical Certification - Employee'S Own Serious Health Condition printable pdf download

NALC Form 1 - Family and Medical Leave Act

Health Care Provider: Please complete this form in order to aid the employer in making its FMLA determination.

Medical Certification—Employee’s Own Serious Health Condition

The employee’s health care provider must complete this form when an employee requests FMLA leave and medical documentation

is required (see ELM Sections 512.41, 513.36 and 515.5). The employee must also complete and submit a PS Form 3971 -

Request for or Notification of Absence.

Employee: Return the completed form to the appropriate FMLA administration HRSSC address or fax (see attached sheet) and keep a copy

for your own records.

Employee’s Name: ______________________________________________________________________________________________________

EIN: __________________________________________ FMLA Case # (if known): __________________________________________________

1. Medical facts:

The back (p. 2) of this form contains sets of medical facts that the FMLA uses to define a serious health condition. Does the

employee’s health condition

match any of these sets of medical facts? If so, please check the applicable set.

❒ 1. Hospitalization ❒ 2. Absence plus Treatment ❒ 3. Pregnancy ❒ 4. Chronic Condition ❒ 5. Permanent/Long-term ❒ 6. Multiple Treatments ❒ None of these

2. Description of medical facts:

Please describe the medical facts that correspond to the set of medical facts checked above. Such medical

facts may include symptoms, hospitalization, doctor visits, whether medicine has been prescribed and any regimen of continuing treatment. A

specific diagnosis or prognosis is not required.

________________________________________________________________________________________________________

3. Duration of the condition

(Be as specific as you can; terms such as “lifetime,” “unknown” or “indeterminate” should be used only when they

reflect your best medical judgment.)

a. Approximate date condition commenced: _____________________ Probable duration of condition: _____________________

❒

4. Is the employee able to perform the essential functions of his or her position?

Yes

If no, please describe the employee’s restrictions and their duration:

________________________________________________________________________________________________________

Will the employee require leave that is medically necessary on an intermittent or reduced schedule basis for planned medical treatment of the

employee’s serious health condition, including pregnancy? ❒ Yes

❒ No

If yes, please provide an estimate of the dates and duration of such treatment(s) and any period(s) of recovery.

Dates: ____________________________________ Duration:

_____ hour(s) or

_____ day(s) per episode.

Period of Recovery: ________________________

Estimate the part-time or reduced work schedule the employee needs, if any:

_____ hour(s) per day; _____ day(s) per week from ___________ through __________.

Will the employee require leave that is medically necessary on an intermittent or reduced schedule basis for the employee’s serious health condi-

❒ Yes

❒ No

tion, including pregnancy, that may result in unforeseeable episodes of incapacity

(e.g. flare-ups)?

If yes, please provide an estimate of the frequency and duration of such episodes of incapacity (e.g. 3 episodes every 2 months lasting 1-2 days):

Frequency: _____ times per _____ week(s) _____ month(s) Duration: _____ hours or _____ day(s) per episode

________________________________________________________________________________________________________

Health Care Provider Signature: ____________________________________________________________ Date:__________________________

Print Name: __________________________________________ _________________________________ Phone: (______)_________________

Medical Practice/Specialty: _______________________________________________________________ FAX: ___________________________

Address: _____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

___________________________

Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave.

Flare-ups or other unforeseeable leave in the case of chronic conditions or pregnancy need not require treatment by a health care provider.

NALC Form 1 (page 1 of 2) - 5/24/2013

Nalc Form 1 - Medical Certification - Employee'S Own Serious Health Condition

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