Medical Certificate

Agency Name:

Attn: Human Resources

Form #: P33A - Employee

Revision Date: 4/2006

To be used by employee who is absent for personal illness, including FMLA absences.

FEDERAL FMLA:

Under the federal FMLA, “Serious Health Condition” is defined as an illness, injury, impairment, or physical or mental condition that involves:

• Any period of incapacity or treatment related to inpatient care (i.e., an overnight stay in a hospital, hospice, residential facility, OR

• Continuing treatment by a health care provider.

“Continuing treatment” by a health care provider includes any one or more of the following:

1) Absence Plus Treatment: A period of incapacity of more than three consecutive calendar days and any subsequent treatment or period of incapacity relating to the same condition, that also involves:

• Treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision of a health care provider, or by a provider of health care services (e.g. physical therapist) under orders of, or on referral by, a health care provider, OR

• Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.

2) Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care.

3) Chronic Conditions Requiring Treatments: Any period of incapacity or treatment for such incapacity due to a chronic condition which:

• Requires periodic visits for treatment by a health care provider or by a nurse physician’s assistant under direct supervision of health care provider;

• Continues over an extended period of time (including recurring episodes of a single underlying condition);

• AND

• May cause episodic rather than a continuing period of incapacity. Examples: asthma, diabetes, epilepsy.

4) Permanent/Long-term Conditions: A period of incapacity, which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples: Alzheimer’s, a severe stroke, or the terminal stages of a disease.

5) Multiple Treatments (Non-Chronic Conditions): Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment. Examples: cancer (chemotherapy, radiation, etc.) severe arthritis (physical therapy), and kidney disease (dialysis).

Note: Substance abuse may be a serious health condition if the conditions mentioned above are met. However, FMLA leave may only be taken for treatment for substance abuse by a health care provider or by a provider of health care services on referral by a health care provider. On the other hand, absence because of the employee’s use of the substance, rather than for treatment, does not qualify for FMLA leave.

Please Note: For the purposes of federal FMLA the following terms are defined to mean:

• “Incapacity” – inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom.

• “Treatment” – includes examinations to determine if a serious health condition exists and evaluations of the condition. It does not include routine physical examinations, eye examinations, or dental examinations.

• A “regime of continuing treatment” – includes, for example, a course of prescription medication (e.g. an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. It does not include the taking of over-the-counter medications such as aspirin, antihistamines, or salves, or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.

STATE FAMILY / MEDICAL LEAVE (C.G.S. 5-248a):

Under the state’s family/medical leave law, “Serious Illness” is defined as an illness, injury, impairment or physical or mental condition that involves:

• Inpatient care in a hospital, hospice, or residential care facility;

OR

• Continuing treatment or continuing supervision by a health care provider [C.G.S. 5-248a(c) and CT State Regulation 5-248b-1(d)].

EMPLOYEE FITNESS FOR DUTY CERTIFICATION

Employee’s name:

Supervisor:

Date leave commenced:

Date of return:

I understand that following my medical leave under federal FMLA and/or C.G.S. 5-248a my restoration to employment is subject to the following conditions:

1. As a condition of restoration, I must provide a written certification from my health care provider certifying that I am able to resume working.
2. Every attempt will be made to restore me to my original position. If my original position is unavailable, I will be placed in an equivalent position with equivalent pay and benefits, unless contract specifies otherwise.
3. If I am returning from unpaid family and medical leave, I shall not be entitled to the accrual of any seniority or employment benefits during the period of leave, unless contract specifies otherwise.

I have examined and can certify that she/he is fully able to resume working on

Name: Telephone:

Address: