Norristown Area School District Family & Medical Leave Forms Kit (Page 6 of 13) in pdf

Certification of Health Care Provider for

U.S. Department of Labor

Employee’s Serious Health Condition

Wage and Hour Division

(Family and Medical Leave Act)

OMB Control Number: 1235-0003

Expires: 2/28/2015

SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require

an employee seeking FMLA protections because of a need for a leave due to a serious health condition to submit a medical

certification issued by the employee’s health care provider. Please complete Section I before giving this form to your

employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide

more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally

maintain records and documents relating to medical certifications, recertifications, or medical histories of employees created

for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance

with 29 C.F.R. §§ 1630.14(c)(1), if the American with Disabilities Act applies.

Employer name and contact: _______________________________________________________________________

Employee’s job title: _____________________________________ Regular work schedule ___________________

Employee’s essential job functions: _________________________________________________________________

_______________________________________________________________________________________________

Check if job description is attached: ______

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The

FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a

request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to

obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient

medical certification may result in a denial of your FMLA request. 20 C.F.R. §§ 825.313. Your employer must give you at

least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).

Your name: ____________________________________________________________________________________

First

Middle

Last

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully

and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition,

treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of

the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to

determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Please be sure to

sign the form on the last page.

Provider’s name and business address: _______________________________________________________________

Type of practice / Medical specialty: ________________________________________________________________

Telephone: (_____)_______________________________ Fax: (_____)___________________________________

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CONTINUED ON NEXT PAGE

FormWH-380-E Revised January 2009

Norristown Area School District Family & Medical Leave Forms Kit Page 6

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