FMLA - Certification of Health Care Provider

FMLA - Certification of Health Care Provider

For all active employees and their covered dependents.

Use this form when a serious health condition effects a Family and Medical Leave Act (FMLA) leave. A serious health condition, as defined by FMLA, is explained on page two of this form.

This form provides medical certification, which is required to support the need for FMLA leave due to a serious health condition affecting you or an immediate family member (spouse or registered same-sex domestic partner, child, or parent).

Instructions

You should provide this form, along with the Employee Request for Family and Medical Leave, as medical certification to your Human Resources Officer no later than the time the leave begins and must be provided within 15 days after medical certification is requested. (Additional certification may be required at 30-day intervals; a health care provider representing the University may contact your health care provider and the University may require a second exam at its expense.)