(Family and Medical Leave Act) ATTENTION: THIS DOCUMENT IS to BE SUBMITTED to HRS ONLY

Certification of Health Care Provider for Family Member’s Serious Health Condition

(Family and Medical Leave Act) **ATTENTION: THIS DOCUMENT IS TO BE SUBMITTED TO HRS ONLY**

SECTION I: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for leave due to your own serious health condition or that of a covered family member. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. Failure to provide complete and sufficient medical certification may result in a denial of your FMLA request. Your employer must give you at least 15 calendar days to return this form.

Name of Employee: Employee ID: Date of Birth:

Home Address: ______City: ______State: _____ Zip Code: ______

Date on which employment with University began: ______Number of years as a regular USM & state employee: ______

Current Department: ______Job Title: ______

Supervisor’s Name: ______Payroll Representative’s Name: ______

Have you been previously granted FMLA by the University for this calendar year? ______If yes, indicate dates ______

Request For: ______Continuous FML ______Intermittent FML Leave to begin on: ______Expected return to work date: ______

Name of family member for whom you are providing care: ______

Relationship:______If family member is son or daughter, indicate date of birth: ______

Describe care you will provide to your family member: ______

______

______

______

Employee Signature Work Phone # Alternate # Date

SECTION II: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the Family Medical Leave Act to care for your patient. Answer all applicable parts below, fully and completely. 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 FMLA coverage. Limit your responses to the condition for which the patient needs leave. Please be sure to sign the form on the last page.

PART A: MEDICAL FACTS

1. Approximate date condition commenced: ______

Probable duration of condition: ______

Mark below as applicable:

2. Is the medical condition pregnancy? No Yes. If so, expected delivery date: ______

3. Describe other relevant medical facts related to the condition for which the patient needs care, such medical facts may include:

______

Diagnosis______Symptoms______Regimen of continuing treatment______

Specialized treatment______

PART B: AMOUNT OF LEAVE NEEDED: When answering these questions, be aware that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care:

4. Will the patient be incapacitated for a single continuous period of time due to his/her medical condition? No Yes

If so, list the beginning and end dates for the period of incapacity: from______to: ______

If the patient’s period of incapacity cannot be determined, indicate the date of next appointment: ______

Explain the care that will be needed by the patient: ______

PART C:

**COMPLETE THIS SECTION ONLY IF CARE WILL BE PROVIDED ON AN INTERMITTENT OR REDUCED SCHEDULE BASIS**

Date intermittent or reduced schedule care is to begin: ______anticipated end date: ______

5. Will the patient require follow-up treatments or appointments, including any time for recovery? No Yes

If so, estimate treatment schedule, including approximate dates of any scheduled appointments and the time required for each appointment, including any recovery period:______

______

6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? No Yes

If so, estimate the hours the patient needs care on an intermittent basis: ______hour(s) per day;

______days per week; from ______through ______

7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities?

No Yes

8. Does the patient need care during these flare-ups? No Yes

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the approximate 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: ______[hour(s)] [day(s)] per episode

Note: Conditions requiring intermittent leave may require recertification by a Medical Practitioner every 30 days

______

(Printed Name of Medical Practitioner) (Signature of Medical Practitioner) (Type of Practice)

______

(Address) (Date) (Telephone Number) (Fax Number)

Employees must submit completed form to:

University of Maryland; Attn: Human Resource Services; ER/LR

620 West Lexington Street, 3rd Floor; Baltimore, MD 21201

Fax: 410-706-0169

E-mail:

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Revised 2/7/18