Fillable Non FMLA Medical Leave Application 3-9-16 (City University of New York)

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Non FMLA Medical Leave Application 3-9-16 (City University of New York)

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The Non FMLA Medical Leave Application 3-9-16 (City University of New York) form is 1 page long and contains:

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File type: PDF

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An employee who may not be eligible for FMLA Leave may apply for Non-FMLA Medical leave.
The employee must complete this form, include the Healthcare Provider Certification, and submit to Human Resources.
APPLICATION FOR NON-FMLA MEDICAL LEAVE
Print Name
License Number
OHRM - Non-FMLA Medical Leave Form - 2015 Page 1
Contract Title
Empl. ID
Department
Signature
Employee Information:
Date
HEALTH CARE PROVIDER'S CERTIFICATION
TO BE COMPLETED BY HEALTH CARE PROVIDER PRINT CLEARLY OR TYPE
Estimated date when employee will be able to return to full, unrestricted duty
I certify that the above facts are true and correct.
Contact information while on leave
Home Phone
Email
Cell Phone
Approximate date condition commenced
Date(s) of treatment(s)
Expected delivery date
Type of Practice
Address
City
State
Zip Code
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):
Medical condition is due to pregnancy
Phone
FAX
Supervisor's Name
Phone
Begin Date
Period of incapacity:
End Date
Is the employee unable to perform any of his/her job functions due to the condition?
Yes
No
If yes, identify the job functions the employee is unable to perform: (Refer to Essential Functions listed in the job description provided by the employer, or as
based upon the employee's own description of his/her job):
Date of submission
College
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Non FMLA Medical Leave Application 3-9-16 (City University of New York)

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Completed 18 December 2020

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