Health Certification Content Guidelines
U.S. Department of Labor Health Certification Forms received from a treating health practitioner should be reviewed by the supervisor or Unit HR Representative with the employee (whenever possible). The review is to include consideration of completeness and clear understanding of need for leave, purpose of leave, frequency of leave and duration of leave. Unclear Form content that cannot be clarified by the employee and incomplete Forms are to be returned to the employee with the FMLA Withdrawal Letter indicating the necessary information. A complete Form should include the information below. Review the entire Form for information that may be located in wrong sections prior to considering withdrawal. These instances are acceptable and FMLA should not be withdrawn if the information is found elsewhere on the Form. Some situations are unique and require review with Senior HR Leaders and Faculty and Staff Disability Services staff. Please use these resources when unsure of Form completeness and clarity. All withdrawn FMLA leave letters must be copied to FSDS.
Question 1. Employee's Name:
A complete Form will include the employee name.
Question 2. Patient's Name (if different from employee):
A complete Form will include the name of the patient when the patient is a family member of the employee.
Question 3. The treating health practitioner checks the applicable type (s) of a serious health condition using the description on page 4 of the Form:
A complete Form may or may not include one or more types of a "serious health condition". If none are checked, verify the accuracy with the employee and offer that the treating health practitioner should review the form. If accurate according to the treatment practitioner and/or employee the leave is not FMLA .
Question 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:
A complete Form will include a description supporting the type of health condition marked above on Question 3. Note: A diagnosis is not required.
Question: 5.a. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient's present incapacity if different):
A complete Form will include the date the condition commenced and duration of condition or duration of present incapacity (inability to work) if different from duration of condition.
Question 5. b. Will it be necessary for the employee to take 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 the response is "Yes", a complete Form will include either the beginning and end dates for the period or a phrase identifying the period i.e., "two weeks". Note the response should be "yes" if Question 6. a. identifies need for treatment.
Question 5. c. If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity:
A complete Form for a Chronic Condition will include a response of yes or no. If yes, the duration will provide the beginning and end dates for the period or a phrase identifying the period i.e., "two weeks".
Question 6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments:
If treatments are required, a complete Form will identify the number of required treatments. However, if the treatment is provided by another health practitioner (6.b.) this section may not be complete and another Medical Certification Form may be required by the health practitioner providing the treatment.
If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number of and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:
If the first section of Question 6.a is completed, a complete Form will include the number of treatments, interval between treatments and period required for recovery if needed. The dates of treatment may or may not be included. Note some employees' treatment may not impact work schedules and not require absence.
Question 6. b. If any of these treatments will be provided by another provider of health services (i.e., physical therapist), please state the nature of the treatments:
If Question 6. a. indicates treatments are needed, a complete Form will identify the treatments or defer to the other health practitioner providing the treatments. In this case, another Medical Certification Form should be completed by the health practitioner providing the treatments.
Question 6. c. If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (i.e., prescription drugs, physical therapy requiring special equipment):
If a continuing regimen is prescribed, a complete Form will include a general description of this regimen.
Question 7. a. If medical leave is required for the employee's absence from work because of the employee's own condition (including absences due to pregnancy or a chronic condition), is the employee unable to perform work of any kind?
A complete Form will include the response of yes or no. If the response is yes, the employee is unable to work. This response should be consistent with the response provided in 5.c. The employee should be placed on the applicable paid/unpaid FMLA leave status for the period identified in 5.c.
Question 7. b. If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee's job (the employee or employer should supply you with information about the essential job functions). If yes, please list the essential functions the employee is unable to perform.
A complete Form will indicate the essential functions the employee is unable to perform if the response to the first part of this question is "yes". A "yes" response and/or listing of essential job functions may invoke the Americans with Disabilities Act Reasonable Accommodation procedural requirement. Please contact the department's HR office and/or FSDS to review implementation requirements.
Question 7. c. If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment?
A complete Form may identify the a need for absence for treatment if 6.a . is completed. Note: treatments may or may not require the employee to be absent from work.
Question 8. a. If leave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation?
If this absence is for the family member of the employee, a complete Form will minimally state yes or no.
Question 8. b. If no, would the employee's presence to provide psychological comfort be beneficial to the patient or assist in the patient's recovery?
If this absence is for the family member of the employee, a complete Form will minimally state yes or no.
Question 8. c. If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need:
If this absence is for the family member of the employee, a complete Form will include the duration of the absence required. This information can be identified with beginning and end dates for the period or a phrase identifying the period i.e., "two weeks".
Signature of Health care Provider:
A complete form will have a signature.
Type of Practice:
A complete Form will identify the type of practice.
Address:
A complete Form will have an address.
Telephone Number:
A complete Form will have a telephone number.
Date:
A complete Form will have a date.
Last Updated February 1, 2008