Fillable FMLA Certification Serious Injury Illness Military Family Form 3-9-16 (City University of New York)

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FMLA Certification Serious Injury Illness Military Family Form 3-9-16 (City University of New York)

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The FMLA Certification Serious Injury Illness Military Family Form 3-9-16 (City University of New York) form is 3 pages long and contains:

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FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER -
MILITARY FAMILY LEAVE
OHRM - FMLA- CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER- MILITARY FAMILY LEAVE FORM - 2015.
Page 1
INSTRUCTIONS TO EMPLOYEE OR CURRENT SERVICEMEMBER:
The FMLA permits CUNY to require that an employee submit a timely, complete, and sufficient certification to support a request for FMLA leave
due to a serious injury or illness of a servicemember. Your response is required to obtain or retain the benefit of FMLA-protected leave. Failure
to do so may result in denial of your FMLA request.
You have at least 15 calendar days to return this form to CUNY.
SECTION I :
TO BE COMPLETED BY THE EMPLOYEE AND/OR THE CURRENT SERVICEMEMBER FOR WHOM THE EMPLOYEE IS REQUESTING LEAVE
This section must be completed first before submitting it to the Healthcare Provider.
PART A: TO BE COMPLETED BY EMPLOYER
Department
Empl. ID
Tel.
Name of Employee
City
Zip Code
State
Relationship of employee to current servicemember (Certification of
Family Relationship Form or other legal documents attached)
Name of current servicemember for whom employee is seeking leave
CERTIFICATION OF FAMILY RELATIONSHIP
FAX
No
Yes
If yes, please provide the servicemember's military branch, rank
and unit currently assigned to:
Is the servicemember a current member of the Regular Armed Forces, the National Guard or Reserves?
PART B: SERVICEMEMBER INFORMATION
No
Yes
Is the servicemember on the Temporary Disability Retired List (TDRL)?
If yes, please provide the name of the medical treatment facility or unit?
No
Yes
Is the servicemember assigned to a military medical treatment facility as an outpatient or to a unit established for the
purpose of providing command and control members of the Armed Forces receiving medical care as outpatients (such as a
medical hold or warrior transition unit)?
Describe the care to be provided to the current servicemember and an estimate of the leave needed to provide the care:
PART C: CARE TO BE PROVIDED TO THE SERVICEMEMBER
This form must be returned by
FMLA FORM - 3 D
College
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER - FOR MILITARY FAMILY LEAVE
State
Zip Code
PART A: HEALTHCARE PROVIDER INFORMATION
SECTION II
FOR COMPLETION BY A UNITED STATES DEPARTMENT OF DEFENSE (DOD) HEALTH CARE PROVIDER OR A HEALTHCARE PROVIDER WHO IS
EITHER : 1) A US DEPT. OF VETERANS AFFAIRS )(VA) HEALTHCARE PROVIDER; 2) A DOD TRICARE NETWORK AUTHORIZED PRIVATE HEALTHCARE
PROVIDER; 3) A DOD NON-NETWORK TRICARE AUTHORIZED PRIVATE HEALTHCARE PROVIDER; 4) A HEALTHCARE PROVIDER AS DEFINED IN THE
FMLA.
If you are unable to make certain of the military-related determinations contained below in Part B, you are permitted to rely upon
determination from an authorized DOD representative (such as a DOD recovery care coordinator).
Type of Practice / Medical Speciality
Country
Zip Code
State
City
Address
FAX
Tel.:
Health Care Provider's Name
OHRM - FMLA- CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER- MILITARY FAMILY LEAVE FORM - 2015. Page 2
INSTRUCTIONS TO THE HEALTHCARE PROVIDER
The employee listed on Page 1 has requested leave under the FMLA to care for a family member who is a current member of the Regular
Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient
status, or is otherwise on the temporary disability retired list for a serious injury or illness.
For purposes of FMLA Leave, a serious injury or illness is one that was incurred in the line of duty on active duty in the Armed Forces or that
existed before the beginning of the member's active duty and was aggravated by service in the line of duty on active duty in the Armed Forces
that may render the servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating.
A complete and sufficient certification to support a request for FMLA leave due to a current servicemember's serious injury or illness includes
written documentation confirming that the servicemember's injury or illness was incurred in the line of duty on active duty or if not, that the
current servicemember's injury or illness existed before the beginning of the servicemember's active duty and was aggravated by service in the
line of duty on active duty in the Armed Forces, and that the current servicemember is undergoing treatment for such injury or illness by a
healthcare provider listed above.
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 FLMLA coverage. Limit your responses
to the servicemember's condition for which the employee is seeking leave. Do not provide information about genetic tests, or genetic services.
PLEASE PRINT CLEARLY OR TYPE. SIGN THE FORM ON THE LAST PAGE (PAGE 3)
NONE OF THE ABOVE
Note to Employee: If this box is checked, you may still be eligible to take leave to take care for a covered family member with a "serious health
condition" under 825.113 of the FMLA. If such leave is requested, you may be required to complete the Certification of Healthcare Provider for
Family Member's Serious Health Condition Form.
OTHER ILL/INJURED
A serious injury or illness that may render the servicemember medically unfit to perform the duties of the member's office, grade, rank, or
rating.
(SI) Seriously Ill/Injured
Illness/Injury is of such severity that there is cause for immediate concern, but there is no imminent danger to life. Family members are
requested at bedside. (Please note that this is an internal DOD casualty assistance designation used by DOD healthcare providers.)
(VSI) Very Seriously Ill/Injured
Illness/Injury is of such severity that life is imminently endangered. Family members are requested at bedside immediately.
(Please note that this is an internal DOD casualty assistance designation used by DOD healthcare providers.)
The current servicemember's medical condition is classified as: (check appropriate box)
PART B: MEDICAL STATUS
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER - FOR MILITARY FAMILY LEAVE
OHRM - FMLA- CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER- MILITARY FAMILY LEAVE FORM - 2015. Page 3
No
Yes
If yes, please describe medical treatment, recuperation or therapy:
Is the current servicemember undergoing medical treatment, recuperation, or therapy for this condition?
No
Yes
Probable duration of condition and/or need for care
Approximate date condition commenced
Is the current servicemember being treated for a condition which was incurred or aggravated by service in the line of duty
on active duty in the Armed Forces?
If yes, please estimate the frequency and duration of the periodic care:
No
No
Yes
Yes
Is there a medical necessity for the servicemember to have periodic care for other than scheduled follow-up treatment
appointments (e.g., episodic flare-ups of medical condition)?
Is there a medical necessity for the servicemember to have periodic care for these follow-up treatment appointments?
If yes, estimate the treatment schedule:
No
Yes
Will the servicemember require periodic follow-up treatment appointments?
To Date
From Date
If yes, estimate the beginning and end dates:
No
Yes
Will the servicemember need care for a single continuous period of time, including any time for treatment and recovery?
PART C: SERVICEMEMBER'S NEED FOR CARE BY FAMILY MEMBER
Signature
Date
License #
Print Name
SIGNATURE OF HEALTHCARE PROVIDER
"Need for care" encompasses both physical and psychological care. It includes situations where, for example, due to his or her serious injury or illness, the servicemember
is unable to care for his or her own basic medical, hygienic, or nutritional needs or safety, or is unable to transport him or herself to the doctor. It also includes providing
psychological comfort and reassurance which would be beneficial to the servicemember who is receiving inpatient or home care.
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FMLA Certification Serious Injury Illness Military Family Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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