Asu Fmla Certification Of Health Care Provider For Employee'S Pregnancy
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1
2
3FMLA CERTIFICATION OF HEALTH CARE PROVIDER
FOR EMPLOYEE'S PREGNANCY
Name ____________________________________
Health Care Provider,
Address ____________________________________
Please return this form
by _________________ to:
____________________________________
____________________________________
Telephone (____) _______________ FAX: (____) _______________
SECTION I: Instructions for Completion by DEPARTMENT
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because
of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care
provider. Please complete the above return address and Section I before giving this form to your employee. Departments must
maintain records and documents relating to medical certifications, re-certifications, or medical histories of employees created for
FMLA purposes as confidential medical records in separate files/records from the usual personnel files.
IMPORTANT: UPON RECEIPT FROM HEALTH CARE PROVIDER, FAX A COPY OF THIS COMPLETED DOCUMENT TO:
HR DISABILITY & LEAVES PROGRAM MANAGEMENT UNIT AT 480.993.0007
Employee’s name ____________________________________________
Employee’s job title: _____________________________________________________________________________________
Employee’s regular work schedule: __________________________________________________________________________
Department name: _________________________________________________________________________________
Department contact: _____________________________________________________________________________________
Provided to employee on: _____________________________________
(MUST BE PROVIDED) Employee’s essential job functions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Check if Job Description, with essential functions, is attached:
SECTION II: Instructions for Completion by the EMPLOYEE
Please type/print your name on the top of page 2 before giving this form to your medical provider. The FMLA permits Arizona
State University (“ASU”) to require that you submit a timely, complete, and sufficient medical certification to support a request for
FMLA leave due to your own serious health condition. If requested by ASU, your response is required to obtain or retain the
benefit of FMLA protections. Failure to provide a complete and sufficient medical certification by the date indicated above may
result in a denial of your FMLA request. These same obligations apply to any and all ASU requests for periodic re-certification.
ENSURE YOUR HEALTH CARE PROVIDER COMPLETES SECTION III & RETURNS THIS FORM BY THE DATE INDICATED
Office of Human Resources | Benefits Design & Management
FMLA Certification of Health Care Provider for Employee’s Pregnancy
Page 1 of 3
Revised: August 2010
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