FMLA Medical Certification Evaluation
Complete this form to certify eligibility for FMLA leave due to a serious health condition. All sections must be filled accurately.
Employee Full Name
*
First Name
Last Name
Employee Contact Email
*
example@example.com
Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Name
*
Employer Contact Email
example@example.com
Healthcare Provider Full Name
*
First Name
Last Name
Healthcare Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Facts Supporting Leave Request
*
Is the medical condition continuous or intermittent?
*
Continuous
Intermittent
Estimated Duration of Leave (in weeks)
*
Date FMLA Leave is Expected to Begin
*
-
Month
-
Day
Year
Date
Date FMLA Leave is Expected to End
*
-
Month
-
Day
Year
Date
Does the employee require a reduced or modified work schedule?
*
Yes
No
Additional Comments or Clarifications
Healthcare Provider's Signature
*
Submit Certification
Submit Certification
Should be Empty: