The Essential Guide to Family & Medical Leave

chapter 8 | Medical Certifications (Proof of Illness) | 159
You may request a medical certification as part of the detailed notice you
must give to an employee who has requested leave for a purpose covered
by the FMLA. (See Chapter 7 for more information on this notice.) If you
instead choose to give the employee a separate written request for a medical
certification, you can use our form, “Request for Medical Certification.”
A sample of this form is below; you’ll also find a copy of this form in
Appendix C and on the CD-ROM at the back of this book.
Sample
To: Sarah Beadle
From: Rayna Harmon
Date: August 23, 2007
Request for Medical Certification
On August 22, 2007, you informed us that you need to take leave for a serious
health condition.
You must submit a medical certification of a serious health condition from your
health care provider. The medical certification form is attached to this letter. Please
note that you must complete a portion of the form if you are seeking leave to care
for a family member.
You must return this form to us by September 7, 2007. If you fail to return this form
on time, we may delay the start of your leave, or postpone the continuation of your
leave, until we receive your certification. If you are unable to return the form on
time due to circumstances beyond your control, please contact me right away.
Feel free to contact me if you have any questions about this requirement.
Sincerely,
Rayna Harmon August 23, 2007
RAYNA HARMON
DATE