Medical Certification For Sick And/or Fmla-Covered Leave Form

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The purpose of this form is to obtain certification for sick leave and/or other leave covered by the FMLA (with
or without pay) for the employee named below. Approximate dates of absence and return are required for this
employee to be granted leave. "Open-ended" certifications cannot be accepted.
Instructions to Health Care Provider: Please complete sections C and E and, if appropriate, the supplement to Section
B. If this request relates to the employee's own illness/injury, a description of the employee's duties is provided in
Section B.
SECTION A: Demographic Information (to be completed by employee)
Employee Name_____________________________________ Title___________________________________
Unit___________________ Home Phone________________ Address________________________________
Patient's Name (if other than Employee)________________________ Relationship______________________
SECTION B: Brief Description of Employee Job Duties (to be completed by Supervisor or Employee
if absence is due to the Employee's medical condition).
Check here (
) if supplemental sheet is attached.
SECTION C: Required Care
Date patient became incapacitated from work/school/daily activities: ____________________________________
Date patient is anticipated to no longer be incapacitated: _____________________________________________
( )YES ( )NO
Did this condition result in in-patient hospitalization (i.e., an overnight stay)?
Describe regimen of treatment prescribed by indicating number of visits, general nature and duration of treatment,
including referral to other provider of healths services.
Answer the following questions if the certification relates to care for the employee's own serious illness.
If this condition makes it medically necessary for the employee to be off work on an intermittent basis or to work
less than his/her normal work schedule, indicate the reduction in hours per day/week
What duties of his/her position is the employee unable to perform because of the serious health condition?
Indicate any accommodations which would enable the employee to perform these functions without posing
a significant risk of injury to the employee or to others.


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