Garfield Re-2 Policies

GBGF-E

Certification of Physician or Practitioner

(Family and Medical Leave Act of 1993)

1. Employee’s name ____________________

2. Patient’s name ____________________

3. Diagnosis ____________________________________________________________

       _______________________________________________________________________

4. Date the condition commenced _____________________________________

5. Probable duration of condition ______________________________________

6. Regimen of treatment to be prescribed.  Indicate number of visits, general nature, and duration of treatment, including referral to other providers of health services.  Include a schedule of visits or treatment if it is medically necessary for the employee to be off work on an intermittent basis or to work less than the employee’s normal schedule of hours per day or days per week.

a. By a physician or practitioner ____________________________

b. By another provider of health services if referred by a physician or practitioner _____________________________________

If this certification relates to care for the employee’s seriously ill family member, skip items 7, 8, and 9 and proceed to items 10 through 14.  Otherwise, continue below.

Check Yes or No in the boxes below as appropriate.

Yes No

7.   Is inpatient hospitalization of the employee required?

8.   Is the employee able to perform work of any kind?  If “no,” skip item 9.

9.   Is the employee able to perform the functions of the employee’s position?  Answer after reviewing a statement from the employer of the essential functions of the employee’s position, or if none provided, after discussing with the employee.

For certification relating to care for the employee’s seriously ill family member, complete items 10 through 14 below as they apply to the family member and proceed to item 17.

Yes No

10.   Is inpatient hospitalization of the family member (patient) required?

11.   Does or will the patient require assistance for basic medical needs, hygiene, nutritional needs, safety, or transportation?

12.   After review of the employee’s signed statement (item 14 below), is the employee’s presence necessary, or would it be beneficial for the care of the patient?  This may include psychological comfort.

13. Estimate the period of time during which care is needed or the employee’s presence would be beneficial.  _______________________________

14. Signature of physician or practitioner ___________________________

15. Date _______________________

16. Type of practice (field of specialization, if any) __________________

Item 17 is to be completed by the employee needing family leave.

17. When family leave is needed to care for a seriously ill family member, the employee must state the care he will provide and an estimate of the time period during which this care will be provided, including a schedule if leave is to be taken intermittently or on a reduced leave schedule.  _________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Employee signature ________________________________________________________

Date _____________________________

 

Issued:  December 12, 2006

Garfield School District No. Re-2, Rifle, Colorado