ࡱ> cfb @ !bjbj '\%\\\\,,,8dL6-pp(i)N,,,,,,$".Rt0F,",\\E, \8i) i) :%,&d t6p,% '-06-%R0b0&\\\\0&"! 9M,,Dd h } hState of Michigan Civil Service Commission Certification of Family Members Serious Health Condition (FMLA) SECTION I For completion by employee. You must submit a certification to support your request for FMLA leave due to a serious health condition of a covered family member within 15 calendar days. Not doing so may result in denial of your request. Please complete Section I before having your relatives health care provider complete Section II. 1. Employees Full Name 2. Covered Family Members Full Name 3. Relationship of Covered Family Member to You:  FORMCHECKBOX  Spouse  FORMCHECKBOX  Parent  FORMCHECKBOX  Child If family member is your child, please provide the childs date of birth: 4. Describe the care you will provide to your family member and estimate the leave needed to provide the care:Employees SignatureDateSECTION II For completion by health care provider. The employee listed above has requested leave under the FMLA to care for your patient. 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. Was medication, other than over-the-counter medication, prescribed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Will the patient need to have treatment visits at least twice per year due to the condition?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Was the patient referred to other health care providers for evaluation or treatment?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, 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. Describe any other relevant medical facts related to the condition (e.g., symptoms, diagnosis, regimen of treatment).14. Will the patient be incapacitated for a single continuous period of time, including any time for treatment or recovery, and will the patient require care during this period?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please estimate the beginning and ending dates for this period: If yes, please explain the care needed by the patient and why such care is medically necessary: 15. Will the patient require follow-up treatments, including any time for recovery?  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 explain the care needed by the patient and why such care is medically necessary: 16. Will the patient require care on an intermittent or reduced schedule basis, including time for recovery?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please estimate the hours the patient needs care on an intermittent basis, if any: __________ hours per day; __________ days per week from _________________ through _________________. If yes, please explain the care needed by the patient and why such care is medically necessary: 17. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities and will the patient need care during these 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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PLP^P`LhH.{pd/                  ^]iQ [ >B  I&NdWh ~@ CE$F%J3 K\LK+N(WX^X>Y6*[=_|U_}nb/cTcEucfTgnkjoTp)q`Sq3ui)x;'|6+v#`sN6@%4bW\C?GC}9P3G,@rw P#?o;A5")O./0qMNchi  !"Kno'(efopO P E F j k +, ""iЕ0V'\'\V'\'\V'\'\ CS-1807CS-1807>;j>;j>;j>;j>;j 0 ( &Unprotect Form Protect FormProtectForm.ProtectFormProject.AutoNew.AutoNewProject.ProtectForm.ProtectForm1Project.ProtectForm.ToolsProtectUnprotectDocumentPROJECT.AUTONEW.AUTONEWPROJECT.PROTECTFORM.PROTECTFORM1PROJECT.PROTECTFORM.TOOLSPROTECTUNPROTECTDOCUMENT@ t@{!@UnknownGz Times New Roman5Symbol3& z Arial5& zaTahoma"(h+&3F o>  > r4d3qH)?C}j Janet Keesler  Oh+'0 0< X d p |j4CS-1807_FMLA_Certification_Employee_Relative.dotJanet Keesler9Microsoft Word 10.0@Z@$^@ fuo@Ώ6p>՜.+,0 hp  State of Michigan    Title  !"#$%&'()*+,-.012345678:;<=>?@ABCDEFGHIJKLMNOPQSTUVWXY[\]^_`adehijklmno|qrstuvwxyz{}~Root Entry F6pg@)Data /1Table90WordDocument'\SummaryInformation(RDocumentSummaryInformation8ZMacros 6pt6pVBA 6pt6pdir9AutoNew ProtectFormpThisDocument H  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGIJKLMNOPQRSTUVWXYZ[\]^_abcdefghijklmnopqrstuvwxyz{|}~50* pHdProjectQ(@= l (J0 J< rstdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\system32\e2.tlb#OLE Automation`EOfficEOficEE2DF8D04C-5BFA-101B-BDE5EAAC42Egram Files\@CommonMicrosoft Shared\@10\MSO.0DLL# 1@0.0 Ob LibraryKEn!ThisDocumentGTisDcumUon] 2 QHB1Bx-B,!}aj"B+B^NewGA t"N!w 2O Mf!E @atFormGRrtc?FrC &2 O#O#I# n!fxMEx (1`*ss` Ne1"  > @` F H B0 .x      (  "0 X x   P 0 @ R`    ( H P < `(  AutoNew MacroH:8 Procedure written 08/02/2000 by Sandra Dailey, Michigani: Department of Civil Service, Office of Technical Services? DocumentView displays document in page layout view (best fit),B turns off view codes, shows paragraph marks, and shows gridlines.; Added code so user would not be asked if they want to save]( their changes to the document template.]@]X !". ($u. ,!.!0 29l949698Z5:(<duqDock customized command bar.\McCS-1807 %>!@CS-1807 %>84v`9@ D9BqHk@I Asking user if they want to print only Exam Announcement & Instructions.* If ans = vbNo Or ans = 1 Then GoTo bye If ans = vbYes ThenmeK ActiveDocument.PrintOut Range:=wdPrintRangeOfPages, Pages:="s1, s3" J  GoTo byeon End If6 Selection.GoTo What:=wdGoToBookmark, Name:="Start"s1, "Returns cursor to top of document.N B@ZRestores window size ,!b dG f ,(bjo{ ans = MsgBox("Would you like to print a copy of the " &' "Examination Announcement and the instructions for completing " &' "the Examination Application?""", vbYesNoCancel + vbQuestion, "Printing Instructions")PôAttribute VB_Name = "AutoNew" Sub 4() '0 Macro@Procedure written 08/02/2000 by Sandra Dailey, MichigantDepartment of Civil Service, OffTechn(icas%.j j&Unprotect Form9 9q6Your document has been protected without updating the form fields. l ProtectedA@FdC@&Unprotect FormCS-1807 ,! %>%.j j &Protect Form9 9q8Your document has been unprotected. YOU MUST REPROTECT ;YOUR DOCUMENT BEFORE PRINTING OR THE TEXT YOU HAVE ENTERED #IN THE FORM FIELDS WILL BE DELETED. l UnprotectedA@Fk8q0o(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 onVe# without resetting the form fields.  rp vt \B@n5x z Display the Protect Dialog box. $. !' *If Cancel was chosen, exit this procedure. G|j Protect the document. ! ~lC@| &Protect FormCS-1807 ,! %>%.j j&Unprotect Form9 9q6Your document has been protected without updating the form fields. l  ProtectedA@Fd unprotect the document.C@&Unprotect FormCS-1807 ,! %>%.j j &Protect Form9 9qh  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. l UnprotectedA@Fkq.oxp#Attribute VB_Name = "ProtectForm" Option Explicit Sub () ' cedure written 9/30/99 by Sandi Dailey, MichiganlDepartment of Civil Service, O ffTechPnicas