Certification Of Health Care Provider (Family And Medical Leave Act Of 1993)

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Form 16874
Rev. 05/10
CERTIFICATION OF HEALTH CARE PROVIDER
(Family and Medical Leave Act of 1993)
SECTION 1: EMPLOYER INFORMATION
Union Pacific Railroad
Employer Name and Contact:
Health & Medical Services Department
1-877-275-8747 option 4
FAX: 402-233-3305
TO BE COMPLETED BY THE EMPLOYEE:
INSTRUCTIONS to the EMPLOYEE: Please complete this section 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. 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).
Employee’s Name: _________________________________
Job Title: ___________________________________________
Employee’s Phone Number: __________________________
Service Unit or Department:_____________________________
Employee ID:______________________________________
Supervisor:__________________________________________
 Birth of an employee’s Child (Estimated due date _______________)
 Block
Reason
Type of
 Own Serious Health Condition
 Intermittent
for leave:
Leave:
Care of:  Parent  Spouse  Child (age ________)
 Reduced Work Schedule
If leave request is for the employee’s own serious health condition:
 Yes
 No
Is the serious health condition for which you are requesting leave related to an on duty injury?
Check if job description is attached: 
List the essential functions of your job: ____________________________________________________________________
If leave request is for the care of a family member:
Describe care you will provide to your family member and estimate leave needed to provide care:
____________________________________________________________________________________________________
Clarification of the Form
The Department of Labor Regulations allows employers to contact your health care provider to clarify the medical certification provided
by the health care provider.
In the event my certification is incomplete or insufficient to determine FMLA coverage:
I prefer that a representative of Union Pacific Health & Medical Services contact my Health Care Provider directly, if necessary
for purposes of obtaining complete information or clarification of the medical certification.
I prefer that the incomplete or insufficient certification be returned to me for the opportunity to cure any deficiencies.
While an employee may choose to comply with the certification requirement by providing the employer with an authorization, release,
or waiver allowing the employer to communicate directly with the health care provider of the employee or his or her covered family
member, the employee may not be required to provide such an authorization, release, or waiver. In all instances in which certification is
requested, it is the employee's responsibility to provide the employer with complete and sufficient certification and failure to do so may
result in the denial of FMLA leave. See Sec. 825.305(d).
Employee’s Signature _________________________________
Date _____________________________
Family Member’s Signature _____________________________
Date _____________________________
Return to: Union Pacific Railroad - Health and Medical Department - 1400 Douglas St. Stop 0350 - Omaha, NE 68179
OR Fax to: 402-233-3305
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