Family Medical Leave Act (Fmla) And Oregon Family Leave Act (Ofla) Forms Packet, Form Cd 1422 - Employee Medical Status Report Page 2
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12HEALTH CARE PROVIDER CERTIFICATION
*For Employee’s Serious Health Condition*
Family and Medical Leave (PD 615A)
Oregon Department of Corrections
This form is used to provide certification per FMLA and OFLA regulations and law.
Section I: Employee Completes this Section
Employee’s name:
Work Location:
Personal E-mail (optional):
Contact Number (optional):
Section II: Health Care Provider Completes this Section
Please complete all sections in order for the agency to determine Family and Medical leave entitlement.
1. Please mark all that pertain to this patient (descriptions are on Page 2 of this certification):
A.
Requires hospital care (hospice, residential care facility)
B.
Requires absence from work plus treatment
C.
Pregnancy disability or requires prenatal care
D.
Chronic condition requiring treatment
E.
Permanent or long-term condition requiring supervision
F.
Requires multiple treatments for a non-chronic condition
G.
None of the above
Describe the medical facts that support the above (such medical facts may include symptoms, diagnosis, surgery or any
regimen of treatment).
2. Approximate date this condition began
3. Estimate the employee’s current dates of incapacity/absence from work
4. Is this for either a chronic condition or for pregnancy?
yes
no If yes, is the patient presently incapacitated?
yes
no If yes, what is the expected duration of the incapacity?
What is the expected frequency of the incapacity?
5. Will it be necessary for the employee to take time off intermittently or work on a reduced schedule due to the patient’s
condition or treatment?
yes
no If yes, what is the expected frequency for the absence?
_____days per week,
______ days per month,
reduce hours worked in a day to ______ for ______ days per
week,
other (describe):
6. Did the patient require treatment (prescription, follow-up appointment, etc.)? Will the patient require a regimen of
treatments?
yes
no If yes to either, describe the nature of the treatments, number of treatments needed and the
intervals between treatments
7. If the patient is not the employee, please use the Family Member Health Care Provider Certification form.
Signature of Health Care Provider
Printed Name of Health Care Provider
Date Signed
Field of Practice:
Health Care Provider Address:
Return form to the patient or FAX to the Oregon Dept. of Corrections, FMLA/OFLA at (503) 362-2078.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal