Connecticut Human Resources Medical Certificate

State of Connecticut Human Resources Medical Certificate

Return to:

Must be submitted within 30 days of foreseeable leave, if leave is FMLA qualifying.

Form #: P33B – Caregiver    Revision Date: 2/2011

To be used by employees seeking family leave to care for a spouse, child, or parent with a “serious health condition/serious illness”.

AGENCY INSTRUCTIONS

This medical certificate is to be used by employees seeking family leave to care for a spouse, child (under age 18 or 18 or older and incapable of self-care because of mental or physical disability), or parent with a “serious health condition” / “serious illness”. It shall be given to the employee or sent directly to the physician or practitioner of the child, spouse or parent who needs care. The name of the person and the address of the agency to which this certificate is to be returned shall be inserted in the space provided. The PHYSICIAN OR PRACTITIONER will generally return the filled out certificate to the agency head or authorized representative. Fill in below the employee’s name, position, and address, and the name of the patient and his/her relationship to employee.

AGENCY FILL IN

CONDITIONS GOVERNING ISSUANCE

This form must be executed by a physician or practitioner whose method of healing is recognized by the State, except where otherwise indicated. Note: The health care provider must practice in the specialty for which the patient is being treated.

No federal FMLA, state family/medical leave (C.G.S. 5-248a), special leave with pay in excess of five (5) days, or leave as otherwise prescribed by contract, shall be granted state employees unless supported by a medical certificate filed with, and acceptable to, the appointing authority. The period of employee absence must be reported with a description of the nature of the patient’s incapacity entered under (2) and/or (7).

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.

(1) Pages 3-4 of this form describes what is meant by a “serious health condition” / “serious illness” under federal FMLA and state family/medical leave (C.G.S. 5-248a). Does the patient’s condition qualify under any of the categories described?

If yes, please check the appropriate category:

(2) If this is for an FMLA qualifying reason, describe the medical facts that support your certification. If additional space is needed, continue remarks under Section (7).

TO BE FILLED IN BY ATTENDING PHYSICIAN OR PRACTITIONER (Please print legibly.)

(3) (a) Answer the following:

(b) If condition is a “chronic condition” state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity:

(4) (a) If additional treatments will be required for the condition, provide:

(b) If any of these treatments will be provided by another provider of health services, state the nature of the treatment and period of time covered.

(c) If a regiment of continuing treatment by the patient is required under your supervision, provide a general description of such regiment.

(5) (a) Does the patient require assistance for basic medical or personal needs or safety, or for transportation?

(b) If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in the patient’s recovery?

(c) If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration and frequency of this need.

(6) The caregiver/employee will be able to return to work on

(7) Additional remarks:

FEDERAL FMLA:

Under the federal FMLA, “Serious Health Condition” is defined as an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by 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.