Medical Certificate 🞏 Absent from Work (first date of absence) 🞏 Not absent from work but requires accommodations (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 Certification (1) The University may require an employee to provide medical certification from a health care provider for FMLA leave without pay when taken for the serious health condition of the employee or the employee's family member. (2) Medical certification may be required to affirm the employee's ability to return to work and perform one or more of the essential functions of the job within the meaning of the Americans with Disabilities Act (ADA), after being absent on FMLA leave.