Certification Of Health Care Provider (Family And Medical Leave Act Of 1993) (Page 2 of 3) in pdf

Form 16874

Employee Name: ____________________________________ Employee ID #: ___________________

Rev. 5/10

TO BE COMPLETED BY THE HEALTH CARE PROVIDER:

INSTRUCTIONS to the HEALTH CARE PROVIDER: Answer, fully and completely, all applicable parts below.

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 “unknown,” “as needed,” or “indeterminate” may not be sufficient to

determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Please be

sure to sign the form on the last page.

Patient’s Name: ____________________________________

If patient is employee’s child - age: ____________

Relationship to Employee: ________________________________

Describe the medical facts which support the certification of the patient’s serious health condition (such medical facts may include

symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

________________________________________________________________________________________________________

Yes

Was the patient admitted for an overnight stay in the hospital, hospice, or residential medical care facility?

Date(s) of admission: __________________

Duration of stay: __________________________

Yes

Is the medical condition pregnancy?

If so, expected delivery date: _____________________________

*Incapacity, for the purposes of FMLA is defined as the inability to perform one or more essential job functions, attend school or

perform other regular daily activities due to the serious health condition, treatment therefore or recovery there from.

What activities of daily living or essential job functions is the patient unable to perform when he or she is incapacitated by their

condition?

________________________________________________________________________________________________________

The patient’s condition does not cause periods of incapacity.

If the patient is incapacitated by their condition, is this a condition that would cause the patient to experience either a:

A onetime continuous block of incapacity

If so when did or when do you expect this period of incapacity to begin? __________________________

How long do you estimate the patient’s period of incapacity will last? ________________________

Episodic flare-ups of incapacity

When did this condition begin? _________________________

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of

flare-ups and the duration of related incapacity.

Frequency (unknown or indeterminate is insufficient to determine FMLA coverage):

______ times per _____ week(s) _____ month(s) ______ year

Duration (unknown or indeterminate is insufficient to determine FMLA coverage):

_______ hours or ________ day(s) per episode

How far into the foreseeable future do you estimate the patient will continue to experience incapacity at the frequency

and duration indicated above?________________________

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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Certification Of Health Care Provider (Family And Medical Leave Act Of 1993) Page 2

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