Fillable Form P33a - Employee Medical Certificate

State of Connecticut Human Resources

Medical Certificate

Return to:

UCONN HEALTH

Agency Name: _________________________________ Attn: Human Resources

16 Munson Rd, Farmington, CT 06034-4035

860-679-4660

Address: ______________________________________________FAX: ______________________

Must be submitted within 30 days of foreseeable leave, if leave is FMLA qualifying.

Form #: P33A - Employee

Revision Date: 2/2011

To be used by employee who is absent for personal illness, including FMLA absences.

This medical certificate is to be used by an employee who is or will be absent for health reasons including the

birth of a child. It shall be given to the employee or sent directly to his physician or practitioner. The name of

AGENCY

the person and the address of the agency to which this certificate is to be returned shall be inserted in the

INSTRUCTIONS

space provided. The PHYSICIAN OR PRACTITIONER will generally return the filled out certificate to the

agency head or authorized representative. Fill in employee’s name, position and address below.

Agency Head or Representative

Agency Name

Leave Coordinator/Human Resources

UCONN HEALTH

Agency Address (No. and Street)

(City or Town)

(State)

(ZIP Code)

16 Munson Rd, Farmington, CT 06034-4035

Employee’s Name and Employee’s Number

AGENCY FILL IN

Employee’s Position

Department

Address (No. and Street)

(City or Town)

(State)

(ZIP Code)

No sick leave, federal FMLA, state family/medical leave (C.G.S. 5-248a), special leave with pay in excess of

five (5) days, or leave as otherwise prescribed by contract, shall be granted state employees unless supported

by a medical certificate filed with, and acceptable to, the appointing authority. The period of incapacity

(including, in the case of pregnancy, the period of time before and after birth when the employee is unable for

medical reasons to perform the requirements of her job) must be reported with a description of the nature of

the incapacity entered under (2) and/or (7).

CONDITIONS

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered

GOVERNING

by GINA Title II from requesting or requiring genetic information of an individual or family member of the

ISSUANCE

individual, except as specifically allowed by this law. 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.

(1)

Pages 3-4 of this form describes what is meant by a “serious health condition” / “serious

illness” under federal FMLA and state family/medical leave (C.G.S. 5-248a). Does the patient’s

condition qualify under any of the categories described? (Please be sure to refer to pp. 3 and 4 for

specific definitions.) ________

If yes, please check the appropriate category:

(fill in “yes” or “no”)

____ Inpatient care with overnight stay

____ Permanent/long-term conditions requiring supervision

____ Incapacity and treatment

____ Multiple treatments (non-chronic conditions)

This form must be

____ Pregnancy (includes prenatal)

____ None of the above

executed by a

____ Chronic conditions requiring treatments

physician or

(2)

If this absence is for an FMLA qualifying reason, describe the medical facts that support your

practitioner whose

certification, including a brief statement as to how the medical facts meet the criteria of one of the

method of healing is

categories on pages 3-4. If this absence is not for an FMLA qualifying reason, describe the medical

recognized by the

facts that support your certification of the employee’s medical condition and incapacity from work. If

State, except where

additional space is needed, continue remarks under Section (7).

otherwise indicated.

____________________________________________________________________________

Note: The health

care provider must

(3)

(a) Answer the following:

practice in the

1. The approximate date the condition commenced. _____________________________

specialty for which

2. The probable duration of the condition. ____________________________________

the patient is being

3. The probable duration of the patient’s present incapacity (if different from (3)(a) 2. above).

treated.

_______________________________________________________________________

4. The date of the employee’s most recent examination for the condition. ______________

(b) Will it be necessary for the employee to take work only intermittently or on a reduced

schedule as a result of the condition (including for treatment described in ITEM (4) below)?

If yes, give the probable duration and frequency.__________________

(fill in no. of months or days, etc.)

(fill in “yes” or no”)

Form P33a - Employee Medical Certificate - 2011

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