Fillable Certification For Employee Non-FMLA - Certification for Employee Non-FMLA

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Certification For Employee Non-FMLA - Certification for Employee Non-FMLA

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1
CERTIFICATION OF HEALTH CARE PROVIDER
FOR EMPLOYEE
Wichita State University *Office of Human Resources* Wichita, Kansas 67260-0015
Phone- (316) 978-3065* Fax- (316) 978-3201
(Rev. 04/06/2015)
SECTION I: INSTRUCTIONS to the EMPLOYEE: Please complete this section before giving this form to your medical provider.
Employee’s Full Name: myWSU ID #
Employee’s Job Title: Regular Work Schedule:
Employee’s Essential Job Functions:
Position Description is Attached: Yes No
SECTION II: INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave. Answer fully and completely, all
applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your 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 leave coverage. Limit your responses to the condition for which the employee is seeking leave.
Please be sure to sign the form on the last page.
Provider’s Name:
Provider’s Address:
Type of practice / Medical specialty:
Telephone: (________) ____________________________ Fax: (________) _____________________________
MEDICAL FACTS
Approximate date condition commenced:
Probable duration of condition:
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No Yes If yes, dates of admission:
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition? No Yes
Was medication, other than over-the-counter medication, prescribed? 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 employee in Section I to answer this question. If the employee fails to provide 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):
2
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: to
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 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 6 months (e.g., 1 episode every 3 months
lasting 1-2 days):
Frequency: times per week(s) month(s). Duration: hours or day(s) per episode.
Additional Information - Identify Question with Your Additional Answer:
____________________________________________ ____________________________
Signature of Health Care Provider Date
* “Incapacity,” for purposes of medical leave, is defined to mean inability to work, attend school or perform other regular activities due to the serious health condition, treatment therefore, or recovery therefrom.
*Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or dental
examinations.
* A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic), or therapy requiring special equipment to resolve or alleviate the health conditions. A regimen
of treatment does not include the taking of over-the-counter medications such as Aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a
visit to a health care provider.
Paperwork Reduction Act Notice and Public Burden Statement
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.Persons
are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that
it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the
Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND
COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OR TO WICHITA STATE UNIVERSITY HUMAN RESOURCES.
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Completed 11 March 2020

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