ࡱ> ad`xy |bjbj 3V{{60PPPddd84d(.<(]D$#{'{'{'{'{'{'$@)+F'-P;"]'K'iiiR8P#i#ii:]!,8!0+j! #'0(!R8,v8,!8,P!i'' ^(8, : State of Michigan Civil Service Commission Certification of Employees Serious Health Condition (FMLA) SECTION I For completion by employee. You must submit a certification to support your request for FMLA leave due to your serious health condition within 15 calendar days. Not doing so may result in denial of your request. You must ensure that your health care provider completes Section II of this form and then returns it to you to ensure its delivery to the office designated below.Return completed form to:  FORMCHECKBOX  DMO  FORMCHECKBOX  HR OfficeAddress:  FORMTEXT      Fax Number: (  FORMTEXT     )  FORMTEXT     -  FORMTEXT     1. Employee s Full Name:2. Employee s Job Title:3. Employee s Regular Work Schedule:4. Employees Essential Job Functions (also refer to any attached job description): SECTION II For completion by health care provider. The employee listed above has requested leave under the FMLA. Answer fully and completely all applicable parts. Please answer all questions based on your medical knowledge, experience, and examination of the patient. Be as specific as you can, but limit your responses to the condition for which the patient needs leave. Please ensure that Section I above has been completed before completing this section. Please attach additional sheets if more space is needed. Please be sure to sign the form.1. Health Care Providers Name and Business Address2. Type of Practice/Medical Specialty3. Telephone:4. Fax:5. Approximate date condition commenced:6. Probable duration of condition:7. Was the patient admitted overnight in a hospital, hospice, or residential medical care facility?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, list the dates of admission: 8. List the dates you treated the patient for the condition:9. Will the patient need to have treatment visits at least twice per year due to the condition?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Was medication, other than over-the-counter medication, prescribed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Was the patient referred to other health care providers for evaluation or treatment?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If so, state the nature of such treatments and expected duration of the treatments: 12. Is the medical condition pregnancy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, expected delivery date: 13. Based on the essential job functions referenced above (or the employees own description if no information is provided by the employer), is the employee unable to perform any job function due to the condition?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, identify the job functions that the employee is unable to perform: 14. Describe any other relevant medical facts related to the condition (e.g., symptoms, diagnosis, regimen of treatment): 15. Will the employee be incapacitated for a single continuous period of time due to the employees medical condition, including any time for treatment or recovery?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please estimate the beginning and ending dates for the period of incapacity: 16. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced-schedule because of the employees medical condition and are the treatments or reduced work schedule medically necessary?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please estimate the treatment schedule, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: If yes, please estimate the part-time or reduced work schedule the employee needs, if any: __________ hours per day; __________ days per week from _________________ through _________________. please explain the care needed by the patient and why such care is medically necessary: 17. Will the condition cause episodic flare-ups preventing the employee from performing the employees job functions and is it medically necessary for the employee to be absent from work during the flare-ups?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, based upon the patients medical history and your knowledge of the medical condition, please estimate the frequency of flare ups and the duration of related incapacity that the patient may have over the next 6 months: Frequency: ____ times per ____ weeks ____ months. 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Z InformationA@X & b` fd \B@^5h j nlpC@l &Protect FormCS-1806 0!&%B%r.V V&Unprotect Form9t x9vq6Your document has been protected without updating the form fields. Z ProtectedA@Xd|C@z&Unprotect FormCS-1806 0!&%B%r.V V &Protect Form9t ~9vq8Your document has been unprotected. YOU MUST REPROTECT ;YOUR DOCUMENT BEFORE PRINTING OR THE TEXT YOU HAVE ENTERED #IN THE FORM FIELDS WILL BE DELETED. Z UnprotectedA@Xk8q0o(X? Procedure written by Sandi Dailey 8-13-99 to Protect/Unprotect9 the active document when using the "Tools" dropdown menu toggle selection.]]]6 If the document is not protected, turns protection on# without resetting the form fields. & b` fd \B@^5h j Display the Protect Dialog box. $. !' *If Cancel was chosen, exit this procedure. G|j Protect the document. !|p nlC@l &Protect FormCS-1806 0!&%B%r.V V&Unprotect Form9t x9vq6Your document has been protected without updating the form fields. Z  ProtectedA@Xd unprotect the document.C@z&Unprotect FormCS-1806 0!&%B%r.V V &Protect Form9t ~9vqh  8Your document has been unprotected. YOU MUST REPROTECT ;YOUR DOCUMENT BEFORE PRINTING OR THE TEXT YOU HAVE ENTERED #IN THE FORM FIELDS WILL BE DELETED. Z UnprotectedA@Xkq.oxp#Attribute VB_Name = "ProtectForm" Option Explicit Sub () ' cedure written 9/30/99 by Sandi Dailey, MichiganlDepartment of Civil Service, O ffTechPnicas