Medical Certificate 🞏 Absent from Work (first date of absence) 🞏 Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Medical Certificates (a) An employee who has given the Employer notice of their intention to take paid or unpaid parental leave, or unpaid partner leave shall provide the Employer with a medical certificate from a registered medical practitioner naming the employee, or the employee’s partner, confirming the pregnancy and estimated date of birth.
Instructions for Certification - Lower Tier Participants (Applicable to all subcontracts, purchase orders and other lower tier transactions requiring prior FHWA approval or estimated to cost $25,000 or more - 2 CFR Parts 180 and 1200)
Instructions for Certification – First Tier Participants a. By signing and submitting this proposal, the prospective first tier participant is providing the certification set out below.