Exelon FMLA Form C-3
Employee Signature
Date
TO BE COMPLETED BY EMPLOYER
You will be required to provide the following information before we can determine whether your leave request qualifies for
FMLA and/or parental leave, as applicable:
A.
____
You will be required to submit a Certification of Health Care Provider Form (Exelon C-1 or C-6, as
applicable). (Completion of this form is necessary to determine your eligibility for FMLA due to your own
serious health condition (i.e., pregnancy, childbirth, recovery from childbirth, etc.) and/or short-term
disability (STD) benefits.)
B.
____
You will be required to submit documentation from the pregnant employee’s health care provider
indicating the name of the pregnant employee and the anticipated date of birth. You may, but are not
required to, have the health care provider complete the Certification below to fulfill this requirement.
C.
____
You will be required to provide documentation of adoption, intent to adopt or placement of a child with
you for foster care. Court and/or agency documents containing this information generally will be
sufficient, but Exelon reserves the right to request clarification and/or further information as necessary to
determine eligibility for FMLA and/or parental leave.
D.
____
You may be required to submit documentation of your relation to the individual giving birth, adopting a
child or accepting a child for foster care.
Please submit the requested information to Occupational Health Services (OHS) within 15 calendar days of your receipt of this
Certification. If you need additional time to obtain the requested information, we expect that you will notify OHS as soon as
possible. Note that failure to provide sufficient documentation to support your request for leave may result in delay or denial
of FMLA and/or parental leave, as applicable.
If you have any questions about your leave request, please contact OHS.
Name: _______________________
Date:______________________
Date this Certification (Exelon FMLA Form C-3) is provided to employee:________________
_____________________________________________________________________________________________
CERTIFICATION OF HEALTH CARE PROVIDER (use only if “B” above is checked)
I certify that ___________________________________ is pregnant and is under my care and that her anticipated due
date is ___________________.
Name of health care provider (please print):_______________________________________________________
Address: _________________________________
City, State, Zip:________________________________
Health Care Providers’ Signature:__________________ Date:_________________________________________
Telephone:____________________________________ Fax #:________________________________________
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