Medical Certification For Sick And/or Fmla-Covered Leave Form Page 3
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1
2
3Supplement to Medical Certification Form
SUPPLEMENT TO SECTION B: Description of Employee Job Duties
The employee's supervisor must list each of the employee's essential job duties in Column 1.
For each duty, the health care provider must complete Columns 2 and 3.
TO BE COMPLETED BY HEALTH CARE PROVIDER
(1) List of Essential Duties
(2) State whether
(3) State any accommodation
(TO BE COMPLETED BY SUPERVISOR)
employee may
which would allow the em-
perform this duty
ployee to perform this duty.
When can this employee return to "light duty" work such as desk jobs for report writing, data evaluation,
computer work, etc.
( )1 week
( )2 weeks ( )3 weeks
( )More than 3 weeks - please explain below.
Note to Supervisors: For positions requiring physical exertion, please be specific in terms of describing weights
and frequency.
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