ࡱ> fie @ vbjbj '\?%\\\\8T87/l\(  +......$#0Ru2F.".\\E.N"N"N"j\8 +N" +N"N":B',' Щt:n' F)/07/x'R242'\\\\2'|rN"%\..D 2"DState of Michigan Civil Service Commission Certification of Serious Injury or Illness of Covered Servicemember SECTION I For completion by employee. You must submit a complete certification to support your request for FMLA leave due to a serious illness of injury to a covered servicemember within 15 calendar days. Not doing so may result in denial of your request. Please complete Section I before having Section II completed. 1. Employees Full Name 2. Covered Servicemembers Full Name 3. Name and Address of Employees Employer4. Relationship of Employee to Covered Servicemember:  FORMCHECKBOX  Spouse  FORMCHECKBOX  Parent  FORMCHECKBOX  Child  FORMCHECKBOX  Next of Kin5. Is the servicemember a current member of the regular Armed Forces, National Guard, or Reserves?  FORMCHECKBOX Yes  FORMCHECKBOX  No If yes, please provide the servicemembers military branch, rank, and unit currently assigned to: 6. Is the servicemember assigned to a military medical treatment facility as an outpatient or to a unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients (such as a a medical hold or warrior transition unit)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please provide the name of the medical treatment facility or unit: 7. Is the servicemember on the Temporary Disability Retired List (TDRL)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No8. Describe the care to be provided to the servicemember and estimate the leave needed to provide the care:SECTION II For completion by (1) U.S. Department of Defense (DOD) health care provider (HCP), (2)U.S. Department of Veterans Affairs (VA) HCP, (3)DOD TRICARE network authorized private HCP, or (4) DOD non-network TRICARE authorized private HCP. The employee listed in Section I has requested leave under the FMLA to care for a relative who is a member of the armed forces. 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 employee is seeking leave. If you cannot make any military-related determination, you may rely upon determinations from an authorized DOD representative. Please ensure that Section I above has been completed before completing this section. Please be sure to sign the form.)1. Health Care Providers Name and Business Address 2. Type of Practice Medical Specialty 3. Telephone:4. Fax:5. Email:6. Indicate which type of health care provider (HCP) you are:  FORMCHECKBOX  a DOD HCP  FORMCHECKBOX  a VA HCP  FORMCHECKBOX  a DOD TRICARE network authorized private HCP  FORMCHECKBOX  a DOD non-network TRICARE authorized private HCP7. The covered servicemembers medical condition is classified as (check one):  FORMCHECKBOX  Very Seriously Ill/Injured (VSI) Illness/Injury is of such a severity that life is imminently endangered. Family members are requested at bedside immediately.  FORMCHECKBOX  Seriously Ill/Injured (SI) Illness/Injury is of such a severity that there is cause for immediate concern, but there is no imminent danger to life. Family members are requested at bedside.  FORMCHECKBOX  Other Ill/Injured A serious illness/Injury that may render the servicemember medically unfit to perform the duties of the members office, grade, rank, or rating.  FORMCHECKBOX  None of the Above 8. Was the condition for which the servicemember is being treated incurred in line of duty on active duty in the armed forces?  FORMCHECKBOX  Yes  FORMCHECKBOX  No9. Approximate date condition commenced: 10. Probable duration of condition and/or need for care:11. Is the servicemember undergoing medical treatment, recuperation, or therapy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please describe: 12. Will the servicemember need care for a single continuous period of time, including any time for treatment or recovery?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please estimate the beginning and ending dates for this period: 13. Will the servicemember require periodic follow-up treatment?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please estimate the treatment schedule: 14. Is there a medical necessity for the servicemember to have periodic care for these follow-up treatment appointments?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 15. Is there a medical necessity for the servicemember to have periodic care for other than scheduled follow-up treatment appointments (e.g., episodic flare ups of medical condition)?  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