Medical Certification Non-Fmla printable pdf download

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): ____________________________________________________________

Medical Certification Non-Fmla