Fmla

Certification of Physician or Practitioner

(Family and Medical Leave Act of 1993)

1. Employee’s Name

2. Patient’s Name (If different from employee)

3. The attached sheet describes what is meant by a “serious health condition” under the Family and Medical Leave Act. (See attachment A). Does the patient’s conditionView footnote 1 qualify under any of the categories described? If so, please check the applicable category.

(1) _____ (2) _____ (3) _____ (4) _____(5) _____ (6) _____, or

None of the above _______

4. Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories:

5a. State the approximate date the condition commenced, and the probable duration of the condition (and also probable duration of the patient’s present incapacityView footnote 2, if different):

b. Will it be necessary for the employee to work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in Item 6 below)? If yes then give probable duration:

c. If the condition is a chronic condition (condition #4) or pregnancy (condition # 3), state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity:

Footnote 1Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave.

Footnote 2“Incapacity,” for purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery there from.

6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments.

If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also...