Equal Employment Opportunity (Eeo) Policy And Program Administration Form Sample Page 39
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54VA MEDICAL CENTER
POLICY MEMORANDUM 00-304
BRONX, NEW YORK 10468
July 31, 2003
ATTACHMENT 3
Certification of Health Care Provider
Bronx V A
Medical Center
(Family and Medical Leave Act of 1993
1.
Employee’s Name:
2. Patient’s Name (if different from employee):
3.
The attached sheet describes what is meant by a serious health condition under the Family and Medical Leave Act
1
(FMLA). Does the patient’s condition
qualify under any of the categories described? If so, please check the applicable
category:
1) ________ Inpatient Hospital Care
5) ________ Permanent/Long-Term Condition
2) ________ Absence Plus Treatment
6) ________ Multiple Treatments (Non-Chronic Condition)
3) ________ Pregnancy
4) ________ Chronic Condition Requiring Treatments
________ None of the Above
____________________________________________________________________________________________________
4.
Describe the medical facts that support your certification, including a brief statement as to how the medical facts meet the
criteria of at least one of these categories of serious health condition:
____________________________________________________________________________________________________
5. A. State approximate date the condition commenced, and the probable duration of the condition (and the probable duration
2
of the patient’s incapacity
, if different):
B. Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result
of the condition (including for the treatment described in Item 6, below)?
Yes
No.
If yes, give the probable
duration:
2
C. If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is currently incapacitated
and the likely duration and frequency of episodes of incapacity:
____________________________________________________________________________________________________
6. A.
If additional treatments will be required for the condition, provide an estimate of the probable number of such
treatments:
B. If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time
basis, please also provide an estimate of the probable number of and interval between such treatments, actual or
estimated dates of treatment (if known), and period of recovery, if any:
C.
If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the
treatments:
1
Here and elsewhere on this form, the information sought relates only to the condition for which the employee is requesting
FMLA leave.
2
“Incapacity,” for purposes of FMLA, is defined to mean inability to work, attend school, or perform other regular daily
activities due to the serious health condition, treatment therefor, or recovery therefrom.
17
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 168a - Equal Employment Opportunity Commission Elementary-secondary Staff Information - Sample - 2004
Legal
Related Categories
Parent category: Legal