Amity School District 4J
Code: GCBDA/GDBDA-AR (3)(B) Adopted: 09/09/09 Revised/Readopted: 08/16/17
Certification of Health Care Provider
Family Member’s Serious Health Condition
To be completed by the district:
The Family Medical Leave Act (FMLA) provides that a district may require an employee seeking FMLA leave 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. Employees may not be asked to provide more information than allowed under the FMLA regulations. The district will maintain records and documents relating to medical certification, recertifications or medical histories of the employee’s family members, created for FMLA purposes, as confidential medical records in separate files from 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.
District contact person:
Employee’s job title:
Regular work schedule:
Employee’s essential job functions:
Check if job description is attached: □
Return this completed form on (date) (must be at least 15 days after employee is notified of this requirement).
To be completed by the employee:
Complete the information below before giving this form to your family member or his/her medical provider. The return of this form is required to obtain or retain the benefit for FMLA protections. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request.
Employee’s name:
First Middle Last
Relationship and name of family member for whom employee will provide care:
Relationship
First Middle Last
If the family member is your child, please provide his/her date of birth:
Describe the care you will provide to your family member and estimate the leave needed to provide such care:
Employee signature Date
To be completed by 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 the 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. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), C.F.R. § 1635.3(b). Extra space is provided, should you need it. Please be sure to sign the form on the last page.
Providers’ name and business address:
Type of practice/medical specialty:
Telephone: ( Fax:(
Email:
Medical Facts
- The approximate date the condition commenced:
The probable duration of the condition:
Was the patient admitted for an overnight stay in a hospital, hospice or residential medical care facility? □ No □ Yes If yes, dates of admission:
List the dates(s) you treated the patient for their 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 yes, state the nature of such treatments and expected duration of treatment:
- Is the medical condition pregnancy? □ No □ Yes
If yes, expected delivery date:
- Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis or any regimen of continuing treatment such as the use of specialized equipment):
Amount of leave needed
When answering these questions, keep in mind that your patient’s need for care from the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs or the provision of physical or psychological care:
- Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? □ No □ Yes
If yes, estimate the beginning and ending dates for the period of incapacity:
During this time, will the patient need care? □ No □ Yes
Explain the care needed by the patient and why such care is medically necessary:
- Will the patient require follow-up treatments, including any time for recovery? □ No □ Yes
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
- Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? □ No □ Yes
Estimate the hours the patient needs care on an intermittent basis, if any:
hour(s) per day; days per week from through
Explain the care needed by the patient, and why such care is medically necessary:
- Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities? □ No □Yes
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next six months (e.g., one episode every three months lasting one to two days):
| Frequency: | times per | week(s) | month(s) |
| Duration: | hours or | day(s) per episode |
Does the patient need care during these flare-ups? □ No □ Yes
Explain the care needed by the patient, and why such care is medically necessary
Additional Information – Identify the question number with your additional answer:
Signature of Health Care Provider Date