Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) printable pdf download

ASU Human Resources

Type: Intermittent or Continuous

DOH: _____/_____/_____

FML BEG: _____/_____/_____

FML END: _____/_____/_____ END REASON: ________________________

Certification of Health Care Provider for

Family Member’s Serious Health Condition

(Family and Medical Leave Act)

SECTION 1: For Completion by the EMPLOYEE

Please complete Section II before giving this form to your family member or his/her medical provider. The

INSTRUCTIONS:

FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request

for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is

required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and

sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer must give you at

least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.

Employee name: ____________________________________________ Banner ___________________________________

Mailing Address: ______________________________City_____________________State______________Zip____________

Best Phone number to contact you: _________________________________ Home Mobile Work (Circle one)

Department:_________________________________________ Email Address: _____________________________________

Employment Status: ____Permanent Full-Time

____ Permanent Part-Time

____ Temporary

How long have you been employed? or Hire Date ___________________________

Name / relationship of Family member for whom you will provide care:

________________________________________________________________________________________

Type of care you will be providing (use back of form if additional space is needed):

__________________________________________________________________________________________

Date Leave is to begin: _______________________ Date Leave is expected to end: _____________________

Employee Signature: _________________________________________________ Date: ________________

SECTION 2: For Completion by the SUPERVISOR

INSTRUCTIONS:

The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA

protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical

certification issued by the health care provider of the covered family member. Please complete Section 2 before giving this form to

your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide

more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain

records and documents relating to medical certifications, re-certifications, or medical histories of employees’ family members,

created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance

with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic

Information Nondiscrimination Act applies.

Employee’s job title: _____________________________________Regular work schedule: ________________________

Employee’s essential job functions: _____________________________________________________________________

__________________________________________________________________________________________________

Supervisor name (Print) _________________________________________Email________________________________

Supervisor Signature __________________________________________ Phone________________________________

Page 1 of 3

Rev 02 25 2016

Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act)

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