Fmla Questionnaire Form (Page 2 of 5) in pdf

Certification of Health Care Provider for Family Member’s Serious Health

Condition (Family and Medical Leave Act)

U.S. Department of Labor Employment Standards Administration Wage and Hour Division

OMB Control Number: 1235-0003 Expires: 5/31/2018

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

leave to care for a covered family member with a serious health condition to submit a medical certification issued by the

health care provider of the covered family member. 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’

family members, 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 Americans with Disabilities Act applies and in

accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.

Employer name and contact: General Dynamics Electric Boat 165 Dillabur Ave North Kingstown RI 02852

Phone: 401-268-2224 Fax: 401-268-2423 E-mail:

SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section

II before giving this form to your family member or his/her 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 to care for a

covered family member with a 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. 29 C.F.R. § 825.313. Your employer must give you at

least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.

Employee name, badge and Dept

Due Date:

Name of family member for whom you will provide care

: _______________________________________

Relationship of family member to you

: __________________________________________________________

If family member is your son or daughter, date of birth: _____________________________________________

Describe care you will provide to your family member and estimate leave needed to provide care:

__________________________________________________________________________________________________

Employee Signature

: _________________________________________________________________________

Date: ______________________________

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380-F Revised May 2015

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