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

Form 16874

Employee Name: ____________________________________ Employee ID #: ___________________

Rev. 5/10

Did the patient have an office visit?

Yes

Date(s) of visit(s): __________________________________________

Scheduled or estimated interval of follow up visit(s) (as needed or indeterminate not sufficient to determine FMLA coverage):

________________________________________________________________________________________________________

Was medication, other than over the counter medication, prescribed?

Yes

Will the patient need to have treatment visits at least twice per year due to the medical condition?

Yes

Will the patient require other treatments in addition to the follow-up visits listed above?

Yes

State the nature of such treatments: __________________________________________________________________________

Date the treatment began: ___________________________

The probable duration of such treatment: _________________

The estimated number of treatments: __________________

The Approximate interval of treatments: __________________

Recovery period due to treatment required: ___________________

Does the employee require a part time or reduced work schedule?  Yes  No

If yes estimate the part-time or reduced work schedule the employee needs ________ hour(s) per day; _________ days per week

from ____________ through ___________

Is it medically necessary for the employee to be absent from work to attend or provide assistance during visits for treatment?

 Yes  No

AMOUNT OF CARE NEEDED (FOR EMPLOYEES SEEKING LEAVE TO CARE FOR A FAMILY MEMBER): When answering these

questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical,

hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care:

Describe the physical or psychological care the patient requires from their family member.

______________________________________________________________________________________________________

What is the probable amount of time away from work the employee will need to provide the assistance to their family member as

described above? (As needed or indeterminate not sufficient to determine FMLA coverage.)

_____________________________________________________________________________________________________

HEALTH CARE PROVIDER INFORMATION

Name (please print):________________________________

Type of Practice / Specialty: __________________________________

Clinic / Hospital: _________________________________

Area Code and Phone Number: _______________________________

Address ________________________________________

Fax Number: ______________________________________________

City:____________________________________________

State: _____________

Zip Code: _____________________

Signature: ____________________________________ Date: ______________________________________________

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. §

825.500.Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of

Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If

you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden,

send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

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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