State of Connecticut Human Resources
Agency Name: _________________________________ Attn: Human Resources
Address: ______________________________________________FAX: ______________________
Must be submitted within 30 days of foreseeable leave, if leave is FMLA qualifying.
Form #: P33A - Employee
Revision Date: 2/2011 To be used by employee who is absent for personal illness, including FMLA absences.
This medical certificate is to be used by an employee who is or will be absent for health reasons including the
birth of a child. It shall be given to the employee or sent directly to his physician or practitioner. The name of
the person and the address of the agency to which this certificate is to be returned shall be inserted in the
space provided. The PHYSICIAN OR PRACTITIONER will generally return the filled out certificate to the
agency head or authorized representative. Fill in employee’s name, position and address below.
AGENCY FILL IN
Agency Head or Representative Agency Name
Agency Address (No. and Street)
(City or Town) (State) (ZIP Code)
Employee’s Name and Employee’s Number
Employee’s Position Department
Address (No. and Street)
(City or Town) (State) (ZIP Code)
No sick leave, federal FMLA, state family/medical leave (C.G.S. 5-248a), special leave with pay in excess of
five (5) days, or leave as otherwise prescribed by contract, shall be granted state employees unless supported
by a medical certificate filed with, and acceptable to, the appointing authority. The period of incapacity
(including, in the case of pregnancy, the period of time before and after birth when the employee is unable for
medical reasons to perform the requirements of her job) must be reported with a description of the nature of
the incapacity entered under (2) and/or (7).
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered
by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law, we are asking that you not
provide any genetic information when responding to this request for medical information. `Genetic information'
as defined by GINA, includes an individual's family medical history, the results of an individual's or family
member's genetic tests, the fact that an individual or an individual's family member sought or received genetic
services, and genetic information of a fetus carried by an individual or an individual's family member or an
embryo lawfully held by an individual or family member receiving assistive reproductive services.
This form must be
executed by a
method of healing is
recognized by the
State, except where
Note: The health
care provider must
practice in the
specialty for which
the patient is being
Pages 3-4 of this form describes what is meant by a “serious health condition” / “serious
illness” under federal FMLA and state family/medical leave (C.G.S. 5-248a). Does the patient’s
condition qualify under any of the categories described? (Please be sure to refer to pp. 3 and 4 for
specific definitions.) ________ If yes, please check the appropriate category:
(fill in “yes” or “no”)
____ Inpatient care with overnight stay ____ Permanent/long-term conditions requiring supervision
____ Incapacity and treatment ____ Multiple treatments (non-chronic conditions)
____ Pregnancy (includes prenatal) ____ None of the above
____ Chronic conditions requiring treatments
(2) If this absence is for an FMLA qualifying reason, describe the medical facts that support your
certification, including a brief statement as to how the medical facts meet the criteria of one of the
categories on pages 3-4. If this absence is not for an FMLA qualifying reason, describe the medical
facts that support your certification of the employee’s medical condition and incapacity from work. If
additional space is needed, continue remarks under Section (7).
(3) (a) Answer the following:
1. The approximate date the condition commenced. _____________________________
2. The probable duration of the condition. ____________________________________
3. The probable duration of the patient’s present incapacity (if different from (3)(a) 2. above).
4. The date of the employee’s most recent examination for the condition. ______________
(b) Will it be necessary for the employee to take work only intermittently or on a reduced
schedule as a result of the condition (including for treatment described in ITEM (4) below)?
If yes, give the probable duration and frequency.__________________
(fill in “yes” or no”)
(fill in no. of months or days, etc.)
Manchester Community College
P.O. Box 1046, MS #2 Manchester CT 06040