Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family Medical Leave Act) Page 3

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ADDITIONAL INFORMATION:  IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER: 
 
____________________________________________________________________________________________ 
 
____________________________________________________________________________________________ 
 
____________________________________________________________________________________________ 
 
____________________________________________________________________________________________ 
 
____________________________________________________________________________________________ 
 
____________________________________________________________________________________________ 
 
 
____________________________________________ 
__________________________________________ 
Signature of Health Care Provider   
 
 
Date 
 
 
Return form to:  Patient or BUREAU OF HUMAN RESOURCES, PMB 0141‐2, 500 E CAPITOL AVE, PIERRE SD 57501 or  
FAX TO: 605.773.6947. 
 
Created: 04/09
3 of 3
Updated 08/15
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