Medical Certification For Sick And/or Fmla-Covered Leave Form Page 2
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2
3( )YES ( )NO
Is employee unable to perform work of any kind because of a serious health condition?
Answer the following if this certification relates to care for the employee's seriously ill family member.
After review of the employee's statement in Section E below, is the employee's presence necessary or would it be
( )YES ( )NO
beneficial for care of the patient (may include psychological comfort)?
Estimate the period of time care is needed or the employee's presence would be beneficial. If it is medically
necessary for the employee to take leave on an intermittent or reduced schedule, please specify.
SECTION D: Release to Return to Work (to be completed by health care provider, if applicable)
Approximate Period/Dates of Absence for Medical Reasons: From__________________ To________________
This employee is released to return to work on _____________________. Restrictions on work duties, if any,
are as follow:
SECTION E: Statement by Employee Needing Family Leave
(to be completed by the Employee if the leave is for a family member)
Please state the care you will provide and an estimate of the applicable time period, including a schedule of care if
leave is to be taken intermittently or on a reduced leave schedule. Please also state to what extent, if any, you
will be engaged in other employment during the leave and the schedule of such employment.
SECTION F: Health Care Provider's Signature
I certify that I am a health care provider for the patient described above. As appropriate, I have reviewed the
statements in Section B (for leave due to the employee's personal serious illness) or those in Section D (for
leave to care for a family member) and have completed this form based on that information and my evaluation
of the patient's medical condition.
________________________________________________
Address_________________________________
Health Care Provider Signature
Date
________________________________________
Type Practice (including speciality, if any)________________ Telephone_______________________________
________________________________________________
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