professional/support staff leaves of absence without pay

G-2931 GCCC-EA
EXHIBIT
EXHIBIT
PROFESSIONAL/SUPPORT STAFF
LEAVES OF ABSENCE WITHOUT PAY
CERTIFICATION OF PHYSICIAN OR PRACTITIONER
(Family and Medical Leave Act of 1993)
1. Employee’s name _________________________________________________________
2. Patient’s name (if other than employee) _______________________________________
3. Diagnosis _______________________________________________________________
4. Date condition 5. Probable duration
commenced _______________________ of condition ___________________
6. Regimen of treatment to be prescribed (Indicate number of visits, general nature and
duration of treatment, including referral to another provodier of health services. Include
schedule of visits or treatment if it is medically necessary for the employee to be off work
on an intermittent basis or to work less than the employee’s normal schedule of hours per
day or days per week.)
a. By physician or practitioner ___________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. By another provider or health services, if
referred by the physician or practitioner _________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
IF THIS CERTIFICATION RELATES TO CARE FOR THE EMPLOYEE’S SERIOUSLY ILL
FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION, SKIP ITEM 7, 8, AND 9
AND PROCEED TO ITEMS 10 THROUGH 16. OTHERWISE, CONTINUE BELOW.
7. Yes No Is inpatient hospitalization of the employee required?
8. Yes No Is the employee able to perform work of any kind? (If
“No,” skip Item 9.)
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G-2931 GCCC-EA
EXHIBIT
EXHIBIT
9. Yes No Is the employee able to perform the functions of the
employee’s position? (Answer after reviewing a statement
from the employer of essential functions of the employee’s
position, or, if none is provided, after discussing it with the
employee.)
10. Yes No Is inpatient hospitalization of the family member (patient)
required?
11. Yes No Does (or will) the patient require assistance for basic
medical, hygiene, nutritional needs, safety, or
transportation?
12. Yes No After review of the employee’s signed statement (see
“Employee Statement” below), is the employee’s presence
necessary, or would it be beneficial for the care of the
patient?
13. Estimate the period of time care is needed or
the employee’s presence would be beneficial. __________________________________
14. Signature of physician or practitioner _________________________________________
15. Date ___________________________________________________________________
16. Type of practice or field of specialty __________________________________________
Employee Statement
Complete the following when family leave is needed to care for a (seriously ill) family member
with a serious health condition or to care for a servicemember.
What care will the employee provide?_______________________________________________
______________________________________________________________________________
______________________________________________________________________________
Estimate what the time period will be during which the employee will care for the family
member. (If intermittent or reduced leave is anticipated, provide a suggested schedule.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________________
Employee Signature
______________________________
Date
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