Certification of Health Care Provider for Employee’s

Serious Health Condition

Family and Medical Leave Act (FMLA)

Section I: For Completion by Denver Public Schools HR Department

Employer Contact Information:

Denver Public Schools

900 S. Grant Street, 1st Floor

Denver, CO 80203

Attn: Human Resources Department

Phone: 720-423-3900

Fax: 720-423-3853

Email:

Section II: For Completion by Employee

Please complete Section II before giving this form to your health care provider. The FMLA permits Denver Public Schools to require that you submit a timely, complete and sufficient medical certification to support your request for FMLA leave due to your own serious health condition. Failure to provide a complete and sufficient medical certification within 15 calendar days from receipt of this form may result in a denial of your FMLA request.

Employee Information:

______First Middle Last Employee ID #

Employee’s Job Title: ______

Description of Job Duties: ______

Employee’s Regular Work Schedule (Days and Hours) ______

Work Location: ______

Work Phone: ______

Home/Cell Phone: ______

Personal Email: ______

Section III: For Completion by the Health Care Provider

Your patient has requested leave under the FMLA. Please answer fully and completely, all applicable parts. Your answers should be your best estimate based on your medical knowledge, experience and examination of the patient. Please be as specific as possible; terms such as “lifetime”, “unknown” or “indeterminate” may not be sufficient to determine FMLA entitlement. Please limit your responses to the condition for which the employee is seeking leave and please be sure to sign the last page of the form.

Please Note: 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.

Health Care Provider’s Name and Business Address:

______

______

Type of practice/medical specialty: ______

Telephone: (______) ______Fax: (______) ______

PART A: MEDICAL FACTS

  1. Approximate date condition commenced: ______

Probable duration of condition: ______

2. Mark below as applicable:

IN-PATIENT CARE: Was the patient admitted for an overnight stay in a hospital, hospice or residential medical care facility? _____ No _____ Yes

If yes, dates of admission: ______

CONTINUING TREATMENT: A period of incapacity of more than three,full consecutive calendar days combined with:

Two or more visits to a health care provider or

One visit to a health care provider and a regimen of continuing treatment

Dates(s) you treated the patient for condition: ______

Was medication, other than over-the-counter medication, prescribed? _____ No _____ Yes

PREGNANCY: Is the medical condition pregnancy? _____ No _____ Yes

If yes, expected delivery date ______

CHRONIC CONDITION REQUIRING TREATMENTS: Will the patient need to have treatment visits at least twice per year due to the condition? _____ 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: ______

______

  1. Use the information provided by the employee in Section II to answer this question. If the job description or essential job functions are not provided, please answer these questions based upon the employee’s 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: ______

  1. 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):

______

PART B: AMOUNT OF LEAVE NEEDED

  1. Will the patient 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: ______

______

If no, will it be medically necessary for the employee to take leave intermittently as a result of the condition? _____ No _____ Yes

If yes, what is the probable duration? ______

  1. Will the patient need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the patient’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 ______

7. 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, please explain: ______

______

Based on 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 my 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 NUMBER WITH YOUR ADDITIONAL ANSWER:

______

Signature of Health Care ProviderDate

1

Denver Public Schools Modeled after DOL

March 2014Form WH-380-E