Certification of Health Care Provider

CODE: GBN-R3

Maine School Administrative District No. 31

CERTIFICATION OF HEALTH CARE PROVIDER

(Family and Medical Leave Act of 1993)

1. Employee’s Name:

2. Patient’s Name (if different from employee):

3. The attached sheet describes what is meant by a “serious health condition” under the Family and

Medical Leave Act. Does the patient’s condition* qualify under any of the categories described? If so,

please check the applicable category.

(1) (2) (3) (4) (5) (6) , or None of the above .

4. Describe the medical facts which support your certification, including a brief statement as to how

the medical facts meet the criteria of one of these categories:

5. a. State the approximate date the condition commenced, and the probable duration of the condition

(also, the probable duration of the patient’s present incapacity** if different):

b. Will it be necessary for the employee to take work only intermittently or to work on a less than

full schedule as a result of the condition (including treatment described in Item 6 below)?

If yes, give the probable duration:

c. If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is

presently incapacitated and the likely duration and frequency of episodes of incapacity:

6. a. If additional treatments will be required for the condition, provide an estimate of the probable

number of such treatments.

If the patient will be absent from work or other daily activities because of treatment on an

intermittent or part-time basis, also provide an estimate of the probable number and interval

between such treatments, actual or estimated dates of treatment if known, and period required

for recovery if any:

b. If any of these treatments will be provided by another provider of health services (e.g., physical

therapist), please state the nature of the treatments.

c. If a regimen of continuing treatment by the patient is required under your supervision, provide a

general description of such regimen (e.g., prescription drugs, physical therapy requiring special

equipment):

7. a. If medical leave is required for the employee’s absence from work because of the employee’s

own condition (including absences due to pregnancy or a chronic condition), is the employee

unable to perform work of any kind?

b. If able to perform some work, is the employee unable to perform any one or more of the

essential functions of the employee’s job (the employee or the employer should supply you

with information about the essential job functions)?

If yes, please list the essential functions the employee is unable to perform:

*Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave.

**“Incapacity,” for purpose of the FMLA, is defined to mean inability to work, attend school, or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom.

c. If neither a. nor b. apply, is it necessary for the employee to be absent from work for

treatment?

8. a. If leave is required to care for a family member of the employee with a serious health condition,

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 of this need:

(Signature of Health Care Provider) (Type of Practice)

(Address) (Telephone number)

To be completed by the employee needing family leave to care for a family member:

State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule:

(Employee signature) (Date)

A “Serious Health Condition” means an illness, injury, impairment, or physical or medical condition that involves one of the following:

1. Hospital Care

Inpatient care (i.e., an overnight stay) in a hospital, hospice or residential medical care facility,

including any period of incapacity* or subsequent treatment in connection with or consequent to

such inpatient care.

2. Absence Plus Treatment

(a) A period of incapacity** of more than three consecutive calendar days (including any subsequent

treatment or period of incapacity** relating to the same condition), that also involves:

(1) 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

(2) 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.

3. Pregnancy

Any period of incapacity due to pregnancy, or for prenatal care.

4. Chronic Conditions Requiring Treatments

A chronic condition which:

(1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s

assistant under direct supervision of a health care provider.

(2) Continues over an extended period of time (including recurring episodes of a single underlying

condition); and

(3) May cause episodic rather than a continuing period of incapacity** (e.g., asthma, diabetes,

epilepsy, etc.)

5. Permanent/Long-term Conditions Requiring Supervision

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 or, but need not be receiving active treatment by, a health care provider. Examples

include Alzheimer’s, a severe stroke, or the terminal stages of a disease.

6. 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, such as cancer (chemotherapy, radiation),

severe arthritis (physical therapy), or kidney disease (dialysis).

First Reading: 12-21-05

Second Reading: 01-25-06

Adopted: 01-25-06

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

**** A regimen 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. A regimen of treatment 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.