It certifies an employee’s serious health condition under the Family and Medical Leave Act (FMLA) so the employee can take job‑protected leave.
The employer or human resources representative completes Section I to provide the employee’s and employer’s information and describe the leave requested.
Section I asks for the employee’s name, dates of leave, type of leave requested and contact information for the employer.
The health care provider completes Sections II and III, verifying the serious health condition and providing medical facts about the condition and need for leave.
A serious health condition is an illness, injury, impairment or physical or mental condition that requires inpatient care or continuing treatment by a health care provider.
The form can be used for continuous, intermittent or reduced‑schedule leave for the employee’s own serious health condition.
Part A asks for medical facts, including the approximate date the condition began, expected duration, treatment schedule and whether the employee can perform essential job functions.
Part B requests information about the type of leave needed, including the frequency and duration of intermittent or reduced‑schedule leave.
