Family & Medical Leave Request and Medical Certification Form. Part 1: EMPLOYEE INFORMATION (to be completed by employee)

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1 New Jersey's Science & Technology University Part 1: EMPLOYEE INFORMATION (to be completed by employee) Name (Please print) Address: City: State _ Zip Telephone: Home If Family & Medical leave is for dependent care, indicate the dependent's first and last name and relationship to the employee: 1. The employee is taking a family leave of absence for the following reason (circle only one) a. to care for the employee's child after birth; (Well Baby Care) b. to care for the employee's child after placement for adoption or foster care; (Well Baby Care) c. to care for the employee's spouse, son, or daughter, or parent who has a serious health condition; or d. for a serious health condition that makes the employee unable to perform the employee's job. NOTE: If the family leave of absence is due to 1.a. or 1.b. above please attach a copy of the birth certificate or adoption or foster care 'placement documents. If you are applying for Family & Medical Leave for 1.a. or 1.b. (Well Baby Care), skip to Part 3. Employee's Certification. Please refer to pages 6 and 7 for the definition of a "Serious Heath Condition". If the Family & Medical Leave of absence is due to 1.c. or 1.d. above please complete the rest of this form and have your health care provider complete Part Does the patient's condition qualify as a "serious health condition"? If so, please identify if the condition involves the following (please circle all that apply): Hospital Care Absence Plus Treatment Pregnancy Chronic Conditions Requiring Treatments Permanent Long-term Conditions Requiring Supervision Multiple Treatments (Non-Chronic Conditions) None of the Above

2 Part 2: Health Care Provider, Please complete this section 3. Describe the medical facts, which support your certification that the patient's condition qualifies as a "serious health condition," including the cause, effect and expected duration of the patient's incapacity'. If it is not obvious to non-medical personnel from the disclosure of the medical condition as to why the condition is work disabling, please explain what is disabling about the condition. Date condition commenced: Probable duration of the condition: Approximate date employee will be able to return to work: 4. If a Family Leave of absence is required for the employee because of the employee's own condition, please describe whether the employee is unable to perform work of any kind; or if the employee is not fully incapacitated, whether the employee is able to perform one or more of the essential functions of the employee's job. (Please advise NJIT if you require information about the essential job functions and it will be provided within 48 hours of your request). If only partially incapacitated, please list those essential functions the employee is unable to perform. 1 "Incapacity," for purposes of Family & Medical Leave of Absence, is defined to mean inability to work or perform other regularly daily activities due to the serious health condition, treatment thereof, or recovery there from. Page 2 of 7

3 ' 5. If this Family Leave of absence is to care for a family member of the employee, under 1.e., with a serious health condition, please describe whether the patient requires assistance for basic medical or personal needs or safety, or for transportation; and/or if the employee's presence to provide psychological comfort would be beneficial (from a health care professional perspective) to the patient or assist in the patient's recovery. 6. The employee will require a Family Leave of absence as a result of the condition (including for treatment described herein) on the following basis: a. Continuous: leave taken for one continuous period of time, for several weeks or more to several months. b. Intermittent: leave taken in separate periods of time due to a single illness or injury, rather than for one continuous period of time, and may include leave of periods from an hour or more to several weeks. C. Reduced: leave schedule that reduces the usual number of hours per workweek, or hours per workday, of an employee. If it is necessary for the patient to work only intermittently or work on a Reduced (less than full schedule) as a result of the condition and/or treatments please describe the probable duration, and medically prescribed work schedule (including days and/or hours) if known and the medical necessity therefore. Page 3 of7

4 7. If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regime (e.g., prescription drug, physical therapy requiring special equipment): With my signature below, I certify that the foregoing is true to the best of my knowledge. (Print Name) (Type of Practice) (Signature of Health Care Provider) (Date Signed) (Address) (Telephone) part 3: Employee Certification! If submitting this form to request Family & Medical 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 that a full schedule: I certify the foregoing is true to the best of my knowledge. I understand that false statements made by me in this application shall be just cause for disciplinary action up to and possibly including termination of employment. I understand I am responsible for advising my supervisor of my dates of absence, anticipated date of return, or other work schedule information but I am required to provide with information relating to medical information only to the Department of Human Resources. If I intend to work for another employer or in my own personal business while on Family & Medical Leave, I understand that I must obtain prior written approval from the Vice -President of Human Resources. I understand that if this form is incomplete or unreadable, Page 4 of7

5 Family &. Medical Leave Request and appropriate representative(s) of NJIT may contact the health care provider listed herein, to release and disclose. both verbally and, in writing, as appropriate to the relevant inquiry, clarification of information pertaining this request for Family & Medical Leave, for the express purpose of determining eligibility for Family & Medical Leave under NJIT policy and Federal and State Regulations. All such information shall be kept confidential to those with a need to know and shall be filed and retained to the extent practicable by the University in a separate medical file. (Signature of Employee) (Date signed) (Please print your name) Please return all pages this Family & Medical Leave Request and Family & Medical Leave Medical Certification form, with original signatures, to Human Resources, NJIT at the address below. If you wish copies for your own personal records, please make the copies before submitting to NJIT If you provide copies of this form to other non-human Resource person(s), Human Resources will not be responsible for confidentiality of those persons. Fax copies are acceptable to expedite the request. However, the original form with original signatures must be received within: (5) days of the fax copy. Page 5 of7

6 Definition of Terms Family &. Medical Leave Request and Definition of Terms A "SERIOUS HEALTH CONDITION" means an illness, injury, impairment, or physical or mental condition that involves one of the following: I. 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 (3) consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves: (1) Treatment two (2) 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 (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 4 under the supervision of the health care provider. 3. Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care. 3 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. 4 A regimen of continuing treatment includes, for example, a course of prescription medication (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. Page 6 of7

7 5. Family &. Medical Leave Request and 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 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 Treatment (Non-Chronic Conditions): Any period of absence to receive multiple treatments (including any period of recovery there from) 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 (3) consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis). Page 7 of7

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