Certification By Service Member'S Health Care Provider For Caregiver Military Family Leave - Fmla Page 2
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1
2MEDICAL STATUS
Briefly state the medical facts regarding the covered service member’s health condition for which FMLA leave is
requested:
Does the injury or illness render the covered service member medically unfit to perform the duties of his or her
office, grade, rank or rating? _____ Yes _____ No
Was the condition for which the covered service member is being treated incurred in line of duty on active duty
in the armed forces? _____ Yes ______ No
Approximate date condition commenced: ______________________________________________________
Probable duration of condition and/or need for care: ______________________________________________
Is the covered service member undergoing medical treatment, recuperation, or therapy? ____Yes ____ No
If yes, please describe medical treatment, recuperation or therapy:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
COVERED SERVICE MEMBER’S NEED FOR CARE BY FAMILY MEMBER
Will the covered service member 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: __________________________________
Will the covered service member require periodic follow-up treatment appointments? ____ Yes ____ No
If yes, estimate the treatment schedule: __________________________________________________________
Is there a medical necessity for the covered service member to have periodic care for these follow-up treatment
appointments? ____ Yes ____ No
Is there a medical necessity for the covered service member to have periodic care other than for scheduled
follow-up treatment appointments (e.g., episodic flare-ups of medical condition)? This can include assisting in the
covered service member’s recovery. ____ Yes ____ No.
If yes, please estimate the frequency and duration of the periodic care: e.g. 2 times per month for 6 months
lasting 3 days.
Frequency: _________ times per _________ week(s) _________ month(s).
Duration: _____________ hour(s) or _________ day(s) per event.
Signature of
Health Care Provider _________________________________________________ Date: _______________________
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