AMITY SCHOOL DISTRICT
Code: GCBDA/GDBDA-AR (3)(A) Adopted: 09/09/09 Revised/Readopted: 08/16/17
Certification of Health Care Provider
Employees 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 due to a serious health condition to submit a medical certification issued by the employee’s health care provider. 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 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 Discrimination 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.
Employees name:_______________________________________________________________ First Middle Last
To be completed by health care provider:
Your patient has requested leave under the FMLA. 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 employee is seeking leave. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29. C.F.R. §1635.3(e) or the manifestation of disease or disorder in the employee’s family members, as defined in 29 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 the 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:
- Use the information provided by the district in the “To be completed by the district” section to answer this question. If the district fails to provide a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s own description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition: □ No □ Yes If yes, identify the job functions the employee is unable to perform:
- 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
- Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? □ No □ Yes
If yes, estimate the beginning and ending dates for the period of incapacity:
- Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee’s medical condition? □ No □ Yes
If yes, are the treatments or the reduced number of hours of work medically necessary?
□ 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:
Estimate the part-time or reduced work schedule the employee needs, if any:
hour(s) per day; days per week from through
- Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? □ No □Yes
Is it medically necessary for the employee to be absent from work during the flare-ups?
□ No □ Yes
If yes, explain:
Based upon the employee’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the employee 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 |
Additional Information – Identify the question number with your additional answer:
Signature of Health Care Provider Date