Family Member Health Certification - Form B
SECTION 1: TO BE COMPLETED BY EMPLOYEE
Information on this form is confidential and private and will be shared strictly on a need to know basis. This form is used for
employee family leaves including those covered by the Family and Medical Leave Act (FMLA).
_______________________________________________________________________________________
Name (Last, First, MI)
SS# (Last 4 Digits)
_______________________________________________________________________________________
Home Address (Street, City, State, Zip)
_______________________________________________________________________________________
Patient’s Name (Last, First, MI)
Date of Birth
Date of Birth: To qualify under the FMLA, if you are taking leave to care for your child, s/he must be under the age of 18. A child
over age 18 may qualify if s/he has a serious health condition, is incapable of self-care, and is incapacitated because of a mental or
physical disability.
Relationship to Employee : ☐ Spouse ☐Mother ☐ Father ☐ Son ☐ Daughter
I authorize release of the information requested on this form to support my family leave request.
_______________________________________________________
Employee Signature
____/____/____
Date
SECTION 2: TO BE COMPLETED BY HEALTH CARE PROVIDER
The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable
parts below. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be
your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms
such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the
condition for which the patient needs leave. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), or
genetic services, as defined in 29 C.F.R. § 1635.3(e). Re-certification may be required.
MEDICAL FACTS REGARDING EMPLOYEE’S FAMILY MEMBER: (Describe the medical facts, such as
symptoms, diagnosis, regimen or continuing treatment, and/or need to use specialized equipment for treatment) ____________
_______________________________________________________________________________________
Approximate date the condition commenced ____/____/____
Probable duration of condition and or/need for care ________________________
(# of days, weeks, months)
Describe the care the family member needs from the employee and an estimate of the leave needed to provide
the care ________________________________________________________________________________
_______________________________________________________________________________________
Stop work date ____/____/____
Return to work date ____/____/____
TREATMENTS: (Treatment includes examinations to determine if a serious health condition exists and evaluations of the
condition. Treatment does not include routine physical examinations)
Send complete form to:
UNH Human Resources, Elizabeth Demeritt House
18 Garrison Ave. Durham, NH 03824 – Fax# 603-862-5159
Created 7/9/2015
Will the family member need care for a single continuous period of time, including any time for treatment and
recovery? ☐ No ☐ Yes If so, estimate the beginning and ending dates for this period of leave
Stop work date ____/____/____
Return to work date ____/____/____
Will the family member require periodic follow-up treatment appointments? ☐ No ☐ Yes If so, provide
an estimate of the treatment schedule ________________________________________________________
_______________________________________________________________________________________
Is there a medical necessity for the family member to have periodic care for these follow-up treatment
appointments?☐ No ☐ Yes If so, provide an estimate of the periodic care schedule __________________
________________________________________________________________________________________
Is there a medical necessity for the family member to have periodic care other than scheduled follow-up
treatment appointments (e.g. basic medical or personal needs or safety, or transportation episodic flare-ups of the medical
issue) ☐ No ☐ Yes If so, please estimate the frequency and duration of the periodic care _______________
________________________________________________________________________________________
If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in
the patient’s recovery? ☐ No ☐ Yes If so, provide an estimate of the periodic care schedule ___________
_________________________________________________________________________________________________________
Provider’s Name ______________________________________________ Phone _____________________
(Please print)
(Area code)
Business Address _________________________________________________________________________
Provider’s Signature _______________________________________________ Date ____/____/____
Send complete form to:
UNH Human Resources, Elizabeth Demeritt House
18 Garrison Ave. Durham, NH 03824 – Fax# 603-862-5159
Created 7/9/2015