Certification By Employee'S Health Care Provider For Employee'S Serious Illness

Certification By Employee'S Health Care Provider For Employee'S Serious Illness - Fmla

FMLA Case # (if known):

Date:

CERTIFICATION BY EMPLOYEE'S HEALTH CARE

PROVIDER FOR EMPLOYEE'S SERIOUS ILLNESS - FMLA

This form is to be

Health Care Provider when

FMLA and medical documentation is required

pursuant to 512.41,513.36 and 515.5 of

ELM. Form PS 3971 must be completed by employee.

Employee's Name:

EIN:

Description of serious health condition

(On the back of this form is the description

"serious health condition" under FMLA. Does the

condition

under any

categories described?

check the

category. In all instances the information

on the form must relate only to the serious health condition for which the current need for leave exists.)

(1) Hospital Care

(3) Pregnancy

__ (5) PermanentILong Term Condition

__ (2) Absence Plus Treatment

__ (4) Chronic Condition

(6) Multiple Treatments (Non-Chronic Condition)

Describe the medical facts and/or treatment that meet the criteria of the serious health condition checked above (this may include the

symptoms, nature of the condition, dates of treatment, or any regimen of continuing treatment such as a course of prescription

medication or therapy requiring use of specialized medical equipment; medical diagnosis/prognosis is not required):

Date condition commenced:

Probable duration of condition:

Probable duration of present incapacity (if different):

Will the employee require leave on an intermittent or reduced schedule basis for planned medical treatment (e.g. follow-up treatment)

of the employee's serious health condition, including pregnancy? _ _Yes _ _No

yes, please provide an estimate of the dates and duration of such treatment and any period(s) of recovery:

Dates:

Duration:

hour(s) or

day(s) per episode

Period of Recovery:

Will the employee require leave on an intermittent or reduced schedule basis for the employee's serious health condition, including

pregnancy that may result in unforeseeable episodes of incapacity (e.g. flare ups)? _ _ Yes _ _ No

yes, please provide an estimate of the frequency and duration of such episodes of incapacity (e.g. 3 times per 1 month

lasting 1-2 days):

Frequency:

times per

week(s)

month(s)

Duration:

hour(s) or

day(s) per episode

Is the employee able to perform the essential functions of employee's position? _ _ Yes _ _No

no, describe the physical restrictions placed on the employee, including the duration of such restrictious.

Health Care Provider's Sig:natm·e:.

Health Care Provider's Name (Please print):

Address:

Telephone Number:

Fax Number:

SpecialtylType of Practice:

(See Page 2 of this Form for Complete Description of FMLA "Serious Health Condition")

APWU Form 1- revised 5/24/12

Page 1

Certification By Employee'S Health Care Provider For Employee'S Serious Illness - Fmla

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