Medical Certification Non-Fmla


Medical Certification non-FMLA (employee’s own medical condition)
1. Employee’s Name
2. Please describe the medical reason necessitating a leave of absence from work:
3. Will it be necessary for the employee to be (please check all that apply and describe below):
___ a) absent from work
___ b) work only intermittently
___ c) work less than a full schedule
and/or work with limitations
If absence from work is required, please provide an estimate of probable duration
b/c) If employee will be able to work only intermittently, less than a full schedule, or has work limitations, please provide:
1) likely duration ___________________________________________________________________________
2) frequency of required absences _____________________________________________________________
3) job related limitations (if any) _______________________________________________________________
4) approved work schedule __________________________________________________________________
4. Please provide:
Date condition commenced:
Probable duration of condition:
Probable duration of current incapacity:_______________
Estimated return to work date:
5. If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of
such regimen (i.e. prescription drugs, physical therapy, etc.)
Signature of Health Care Provider: ____________________________________________
Date: __________________
Printed name of Health Care Provider: ___________________________________________ Phone: _________________
Type of Practice (Field of specialization, if any): ____________________________________________________________


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Parent category: Business