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HEALTH CARE PROVIDER CERTIFICATION

** Family Member’s Serious Health Condition Form**

Family and Medical Leave

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: _______________________________________________________

Patient’s name: _________________________________________________________

The patient is my (Please circle one):

spouse

parent

child (age _____)

same sex domestic partner

parent-in-law

grandparent

grandchild

parent of domestic partner

child of a domestic partner (age ___)

Section II: Health Care Provider Completes this Section

INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for

your patient. 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 “lifetime,” “unknown,” 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 and

fax completed form to (503) 362-2078.

Provider’s name and business address:______________________________________________________________

Type of practice / Medical specialty: ______________________________________________________________

Telephone: (________)____________________________ Fax:(_________)_______________________________

PART A: MEDICAL FACTS

1. Approximate date condition commenced: _________________________________________________________

Probable duration of condition: _________________________________________________________________

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

___No ___Yes. If so, dates of admission: _______________________________________________________

Date(s) you treated the patient for condition: ______________________________________________________

Was medication, other than over-the-counter medication, prescribed? ___No ___Yes.

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

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?

____ No ____Yes. If so, state the nature of such treatments and expected duration of treatment:

2. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such

medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of

specialized equipment):

3. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ______________________

Family Medical Leave Act (Fmla) And Oregon Family Leave Act (Ofla) Forms Packet, Form Cd 1422 - Employee Medical Status Report Page 4