Certification For Injury Or Illness Of Covered Service Member For Military/family Leave (Fmla) Form
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1
2MUST BE RETURNED TO THE OFICE OF
HUMAN RESOURCES NO LATER THAN
____________________ ___________________
CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF COVERED SERVICEMEMBER
FOR MILITARY FAMILY LEAVE (FMLA)
EMPLOYEE/SERVICEMEMBER INFORMATION (to be completed by Employee or Servicemember)
Name of Employee Requesting Leave to Care for Covered Servicemember:
Name of Covered Servicemember for whom employee is requesting leave to care:
Relationship of Employee to Covered Servicemember: Spouse Parent Son Daughter Next of Kin
Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves?
_____ No _____ Yes If yes, provide covered servicemember’s military branch, rank and unit currently assigned to:
Is the covered servicemember assigned to a military medical treatment facility as an outpatient or to a unit
established for the purpose of providing command control of members of the Armed Forces receiving medical care
as outpatients (such as a medical hold or warrior transition unit)? ____ No ____ Yes If yes, please provide the
name of the medical treatment facility or unit:
Is the Covered Servicemember on the Temporary Disability Retired List (TDRL)? _____ Yes
____ No
Describe Care to Be Provided to Covered Servicemember and an Estimate of Leave Needed to Provide Care:
T
:
O BE COMPLETED BY SERVICEMEMBER TO PERMIT CONTACT WITH HEALTH CARE PROVIDER
U
I [ do /
do not] give the College permission to contact my health care provider(s) in order to clarify any medical
certification submitted to justify my family member’s leave. Note: Your failure to give permission will be one of
the factors the College considers in determining whether to request a second medical opinion.
Servicemember Signature
Date
HEALTHCARE PROVIDER INFORMATION
(1)
Covered Servicemember’s medical condition is classified as (Check one of the appropriate boxes):
(VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently
endangered. Family members are requested at bedside immediately. (Please note this is an
internal DOD casualty assistance designation used by DOD healthcare providers.)
(SI) Seriously Ill/Injured – Illness/Injury is of such severity that there is cause for immediate
concern, but there is no imminent danger to life. Family members are requested at bedside.
(Please note this is an internal DOD casualty assistance designation used by DOD healthcare
providers.)
OTHER Ill/Injured – a serious injury or illness that may render the servicemember medically
unfit to perform the duties of the member’s office, grade, rank, or rating.
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