Paid Leave Serious Health Condition Certification Form

Paid Leave Serious Health Condition Certification Form
Submit this form to certify a serious health condition for paid leave purposes. Required sections include employee and healthcare provider information, leave details, and certification.
Employee Full Name
First NameLast Name
Employee Email Address
example@example.com
Employee Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Job Title
Department
Type of Leave Requested
Leave Start Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expected Return Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Brief Description of Serious Health Condition (do not include diagnosis)
Healthcare Provider's Name
First NameLast Name
Healthcare Provider's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Healthcare Provider's Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Signature of Employee or Healthcare Provider
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