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Employee's Certification of Own Serious Health Condition


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Employee's Certification of Own Serious Health Condition

Family and Medical Leave Act of 1993 (FMLA)


Employee Name (Print):________________________________________________________________

1. Description of serious health condition:  To qualify for your own serious illness under the FMLA, your condition must qualify as a “serious health condition” under the definition in the law.  Does your condition qualify under any of the categories described?  (See Definition of “Serious Health Condition” form.)  If so, please check the applicable category.

     1__   2__   3__   4__   5__   6__

2.  Duration of the condition:__________________________________________________________

  • Date the condition began:_________________________________________________________
  • Probable duration of the condition:

Employee Signature and Date:_________________________________________________________________

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