Employee Leave Forms

Medical Certificate form: Employee

Description: 

CERTIFICATION OF PHYSICIAN OR PRACTITIONER EMPLOYEE HEALTH CONDITION Return to: Human Resources, 677 East 12th Ave., Ste. 400
5210 University of Oregon, Eugene OR 97403-5210
Fax: 541-346-2548
I. Employee's Name:
A. If the employee’s condition qualifies under any of the following categories for serious health conditions, please check them. See back for a definition of each category.
 (1) Hospital Care  (4) Chronic Conditions Requiring Treatments
 (2) Absence Plus Treatment  (5) Permanent/Long-term Conditions Requiring Supervision
 (3) Pregnancy (Incapacity)  (6) Multiple Treatments (Non-Chronic Conditions)
 None apply
B. Describe the medical facts that support the category you checked:
C. Date condition commenced:
D. Length of incapacitation:
II. First Day off Work:
A. Is employee able to perform work of any kind during the period of incapacity?
 Yes  No (If ‘no’, skip to III)
If yes, please describe:
 Reduced Schedule Date Reduced Schedule begins:
Please indicate number of hours per day/days per week, etc. employee may work.
 Intermittent Leave Date Intermittent Schedule begins:
Please describe schedule and length of time for intermittent leave schedule. Regimen of treatment to be prescribed. (Indicate number of visits, general nature and duration of treatment, including referral to other provider of health services. Include 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.)
B. Is employee able to perform the functions of employee's position during the period of incapacity? (Answer after reviewing statement from employer of essential functions of employee's position or, if none provided, after discussing with employee).
 Yes, can perform all functions.
 No, cannot perform at least one of the functions. List functions employee is unable to perform:
III. Date employee can return to regular work without restrictions:
Signature of Health Care Provider Date
Address Type of Practice
A “Serious Health Condition" means an illness, injury, impairment, or physical or mental 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 incapacity1
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) Treatment2
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 treatment3
under the supervision of a 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:
a. 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;
b. Continues over an extended period of time (including recurring episodes of a single underlying condition); and
c. 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 of, 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, etc.), severe arthritis (physical therapy), kidney disease (dialysis)
NOTE TO CARE PROVIDER: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
1"Incapacity," for purposes of 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.
2Treatment 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.
3A 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.

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Medical Certificate form: Family

Description: 

CERTIFICATION OF PHYSICIAN/PRACTITIONER
FAMILY MEMBER HEALTH CONDITION
RETURN TO: Human Resources, University of Oregon, 677 East 12th Ave., Suite 400, Eugene OR 97403-5210 - fax 541-346-2548
1. Employees Name: 2. Family Member/Patient’s Name (and relationship to employee):
_______________________________________
3. If the patient’s condition1 qualifies under any of the following categories for serious health conditions, please check them. See back for a definition of each category.
_____ 1. Hospital Care _____ 4. Chronic Conditions Requiring Treatments
_____ 2. Absence Plus Treatment _____ 5. Permanent/Long-term Conditions Requiring Supervision
_____ 3. Pregnancy (Incapacity) _____ 6. Multiple Treatments (Non-Chronic Conditions)
_____ None Apply _____ 7. Injured or Ill Servicemember
Describe the medical facts that support the category you checked: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
4. Date patient’s condition commenced: 5. Probable Duration of patient’s incapacity:
____________________________________ __________________________________________
6. Does the patient require assistance for basic medical, hygiene, nutritional needs, safety or transportation? Yes _____ No _____
7. After review of the employee’s signed statement below, is the employee’s presence necessary or would it be beneficial for the care of the patient? (This may include psychological discomfort.) Yes _____ No _____
8. Estimate the period of time care is needed or the employee’s presence would be beneficial:
TO BE COMPLETED BY THE EMPLOYEE NEEDING FAMILY LEAVE
When Family Leave is needed to care for a seriously ill family member, the employee shall state the care he or she 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: ______________
9. Print name of Physician or Practitioner: ______________________________________ Date: _______________________
10. Print Type of Practice (Specialization, if any) ___________________________________________________________________
Signature of Physician or Practitioner ____________________________________________________________________________
1 Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA/OFLA leave. Jan 2014
A “Serious Health Condition” means an illness, injury, impairment, or physical or mental 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 incapacity2 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) Treatment3 two or more times by health care provider, by a nurse or physician’s assistant under direct supervision of 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 treatment4 under the supervision of a 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:
a. 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.
b. Continues over an extended period of time (including recurring episodes of a single underlying condition); and
c. 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 of, 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, etc.), severe arthritis (physical therapy), kidney disease (dialysis).
NOTE TO CARE PROVIDER: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
2 “Incapacity,” for purposes of 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.
3 Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, or dental examinations.
4 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.

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Protected Leave Request Form (FMLA/OFLA)

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FMLA Status Report

File attachments: 
Description: 
Employee Status Report DO NOT INCLUDE MEDICAL DIAGNOSIS. Current Status Restrictions (limitations: sit, stand, walk) Bend, Climb, Crawl, Push, Pull, Reach (above shoulder), Squat Lift/Carry, Push/Pull Use of Hands Estimated time for modified duty Medically Stationary?
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FMLA/OFLA Attendance Record

Description: 
FMLA/OFLA ATTENDANCE RECORD Return to Human Resources by the 10th of each month. NAME: ____________________________________________ DEPARTMENT: _______________________________________ Instructions: Indicate the number of hours you are off each day while on FMLA/OFLA leave. Include hours off for the entire month. Please do not submit this form with midmonth to midmonth hours. Include holidays as FMLA/OFLA leave if you are off on a continuous basis. Do not include days you are not expected to work (i.e., unpaid winter, spring, summer breaks). Intermittent leave: You must submit this form even if “0” hours were taken. Enter a zero in the ‘total’ box for the appropriate month. You may find this form at: http://hr.uoregon.edu/benefits/fmla/attend.pdf. Time Sheet/Leave Reporting: Continue to submit your regular time sheet or report leave for payroll purposes. Are any of these hours off work associated with an injury or condition for which you have filed a workers compensation claim? Please check the appropriate box. Yes, all of the hours indicated above are due to my on-the-job injury or condition. Yes, some of the hours indicated above are due to my on-the-job injury or condition. (Please circle only the hours associated with an on-the-job injury.) No, none of the hours indicated above are due to my on-the-job injury or condition. Employee Signature: Date: Supervisor Signature: Date: Note to Supervisor: If you change the hours reported by the employee, please have your employee initial here in agreement to the change. Initials Date:
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Bereavement Request Form

File Type (ext): 
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OFLA Sick Child Leave Attendance Record

File Type (ext): 
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