Family And Medical Leave Act (Fmla) Certification Form
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1FAMILY AND MEDICAL LEAVE ACT (FMLA) CERTIFICATION FORM
Employee’s Section
Employee’s Name:
______________________________________________________________
Banner ID Number:
______________________________________________________________
Employee’s Department:
______________________________________________________________
Patient’s Name (if patient is not employee): ______________________________________________________________
Medical Release-My signature authorizes the release of any medical information needed by the College of William and Mary and
the Virginia Sickness and Disability Program (Reed Group) for the certification of FMLA. I understand that FMLA may be
denied if the information is not provided, is unclear or incomplete.
Employee’s Signature: __________________________________________________ Date Signed __________________
Patients’ Signature _____________________________________________________ Date Signed __________________
(if patient is not employee):
Reason for FMLA Leave:
□
Employee’s (your) own medical condition.
Employee’s spouse/parent/dependent medical condition; check one of the following:
□
Employee’s Spouse
Parent
Dependant 18 or over
Dependent under 18
Birth, Foster Placement/Adoption of a child
Provider’s Section
Thank you for completing your patients FMLA Leave Certification. Please retain a copy of this completed form in the event the
College or Virginia Sickness and Disability Program (Reed Group) needs to verify its contents. THIS FORM WILL BE
RETURNED IF ALL AREAS ARE NOT COMPLETED IN FULL.
Employee or Employee’s spouse/parent/dependent’s medical condition:
1.
Length of time your patient has had/will have this condition: ____/____/____To____/____/____
2.
This condition is:
Acute (Absence Treatment)
Chronic/Permanent expected frequency of absence
______Days per month lasting _____ hours per absence
Pregnancy, EDC Date: ____/____/____
3.
Relating to this condition:
□
Hospitalization: Admit date: ____/____/____ Discharge date: ____/____/____
□
PT/OT _________ Times per week
□
Follow up appointment dates: ____/____/____, ____/____/____, ____/____/____
□
Other treatment: __________________________________________________________________
□
The employee cannot perform the essential function of his/her job.
4.
Medical facts that support this request:_________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Provider Signature: _______________________________________________________Date: ________________________
Provider Name: __________________________________________________________Tax ID#______________________
Provider Address: _____________________________________________________________________________________
Provider Phone: _____________________________________Provider Fax: ______________________________________
Birth/Placement of a child
Name of Child:
________________________________________________________________________
You must include documentation supporting the date of the child’s birth, adoption, or placement:
Newborn: DOB____/____/____
Foster Child Placement, Date of Placement: ____/____/____
Date of Adoption: ____/____/____
To be completed by Human Resources: Date Form Received: __________________ Letter Mailed ___________________________
Revised 07/2016
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