SmartResumeWizard
?
457203
462361
Certif
i
c
a
t
i
on
of
Health
Care
Pro
v
i
d
er
for
U.S.
De
p
a
r
tme
n
t
of
La
b
or
Emplo
y
ee’s
Ser
i
ous
H
e
alth
Con
d
ition
Wage
and
Ho
u
r
Di
v
ision
(Family
and
M
e
dical
L
eave
Act)
454025
1188861
DO
NOT
SEND
C
OMP
L
ETED
FO
R
M
TO
THE
DE
PA
RTMENT
OF
L
A
BOR;
RE
T
URN
TO
T
H
E
PATIE
N
T
OMB
Control
N
u
m
b
er:
123
5
-
0
0
0
3
Expires:
5
/3
1
/2
0
18
SECTION
I:
F
o
r
Compl
e
ti
o
n
b
y
the
EMPLOYER
INSTRUC
T
IONS
to
the
EMPL
O
YER:
T
h
e
F
a
m
ily
and
M
edical
Leave
Act
(FMLA)
p
rovides
t
h
at
an
e
m
plo
y
er
may
require
an
emplo
y
ee
seeking
FMLA
p
rotections
beca
u
se
of
a
need
for
leave
d
ue
to
a
serious
h
ealth
con
d
ition
to
s
u
b
m
it
a
medical
certi
f
ication
issued
by
t
h
e
e
m
plo
y
e
e
’s
health
care
p
rov
i
de
r
.
Please
co
m
p
l
ete
Section
I
bef
o
re
gi
v
ing
this
f
o
rm
to
your
e
m
plo
y
e
e.
Your
resp
o
nse
is
vo
l
u
n
t
a
r
y
.
While
you
are
not
required
to
u
se
this
for
m
,
y
ou
may
not
ask
t
h
e
emplo
y
ee
to
pro
v
ide
m
ore
i
n
f
o
r
m
ation
t
h
an
all
o
wed
un
d
er
t
h
e
FMLA
regulati
o
ns,
2
9
C.F
.
R.
§§
8
2
5
.30
6
-825.308.
Employers
m
ust
generally
maintain
records
and
doc
u
m
ents
relati
n
g
to
medical
certi
f
icatio
n
s,
recertificati
o
ns,
o
r
medical
his
t
o
r
ies
of
e
m
plo
y
ees
creat
e
d
for
F
MLA
p
u
rposes
as
co
n
fi
d
ential
medical
re
c
ords
in
separate
files/recor
d
s
fr
o
m
the
us
u
al
p
ersonnel
files
and
in
accordance
wi
t
h
29
C.F.R.
§
1630.
1
4
(
c)(1),
if
the
America
n
s
with
D
i
sabilities
Act
ap
p
lies,
a
n
d
i
n
accordance
with
2
9
C
.F.R.
§
163
5
.9,
if
the
Genetic
Inf
o
r
m
ation
Non
d
iscr
i
m
ination
Act
ap
p
lies.
457200
3192745
E
m
plo
y
er
name
and
contact:
_
_
_
____
_
_____
_
_______
_
_____
_
_______
_
_______
_
_____
_
_
_
_____
_
________
457200
3513549
E
m
plo
y
ee’s
job
title:
____
_
___
_
_____________
_
______
Reg
u
lar
work
schedule:
_
_
_
_______
_
____________
457199
3835113
E
m
plo
y
ee’s
essential
job
f
u
ncti
o
ns:
_____
_
_____
_
_______
_
_______
_
_____________
_
_______
_
_____
_
_
_
_
__
457199
4156677
_____
_
_______
_
_____
_
_______
_
_______
_
_____________
_
_______
_
_____
_
_______
_
_____________
_
____
457199
4477481
Check
if
job
descrip
t
ion
is
attached:
457198
4794755
SECTION
II
:
F
o
r
Completion
b
y
the
EMPL
O
Y
E
E
INSTRUC
T
IONS
to
the
EMPL
O
YEE:
Please
complete
Secti
o
n
II
b
efore
g
iving
this
form
to
y
o
u
r
m
edical
pr
o
v
i
der.
The
FMLA
p
e
r
m
its
an
e
m
plo
y
er
to
require
t
h
at
you
sub
m
it
a
t
i
mel
y
,
co
m
plete,
and
s
u
fficient
medical
cert
i
fication
to
supp
o
rt
a
request
for
F
MLA
leave
due
t
o
y
our
o
wn
serious
he
a
lth
co
n
d
i
tion.
If
requested
by
y
o
ur
e
m
plo
y
er,
y
o
u
r
response
is
required
to
obtain
or
retain
the
be
n
efit
of
FMLA
protections.
29
U.S.C.
§
§
2613,
26
1
4(c)(3).
Fail
u
re
to
pro
v
ide
a
c
o
m
plete
and
sufficient
m
edical
certific
a
tion
m
ay
result
in
a
d
enial
of
yo
u
r
F
MLA
request.
20
C.F.R.
§
825.3
1
3.
Yo
u
r
e
m
plo
y
er
m
ust
give
y
ou
at
least
1
5
cale
n
dar
da
y
s
to
return
t
h
is
f
o
r
m
.
29
C.F
.
R.
§
825.
3
05(b).
457198
6084808
Your
n
ame:
______
_
_______
_
_____
_
_______
_
_______
_
_____
_
_
_
_____
_
_______
_
_____
_
_______
_
_______
_
_
First
Midd
l
e
Last
457196
6562094
SECTION
II
I:
F
o
r
Com
p
letion
b
y
the
HEALTH
C
ARE
P
R
OVIDER
INSTRUC
T
IONS
to
the
HEALTH
C
ARE
P
R
OVIDER:
Yo
u
r
patient
has
requested
leave
u
n
d
er
the
FMLA.
Ans
w
er,
fully
and
completel
y
,
all
applicable
p
arts.
S
everal
q
uestions
seek
a
response
as
t
o
t
h
e
frequency
or
duration
o
f
a
cond
i
tion,
trea
t
m
ent,
etc.
Yo
u
r
answer
shou
l
d
be
your
b
est
estimate
based
upon
y
o
ur
medical
kn
o
wled
g
e,
e
xperience,
and
examination
o
f
the
patie
n
t.
Be
as
speci
f
ic
as
y
ou
can;
te
r
ms
such
a
s
“lifet
i
me,”
“u
n
know
n
,”
or
“indete
r
m
inate”
m
ay
n
ot
be
sufficient
to
d
eter
m
ine
FMLA
cover
a
ge.
Limit
y
our
resp
o
nses
to
t
h
e
co
n
dition
for
which
the
e
m
p
l
o
y
ee
is
seeking
leave.
Do
not
p
r
o
vide
info
r
m
ation
about
ge
n
etic
tests,
as
d
efined
in
2
9
C
.
F.R.
§
1635.
3
(f),
genetic
service
s
,
as
defined
in
29
C
.F
.
R.
§
1635.3(e),
o
r
the
manifestati
o
n
of
disease
or
d
isor
d
er
in
t
h
e
e
m
ployee’s
fa
m
ily
m
e
m
bers,
29
C.
F
.R.
§
1
6
35.3(
b
).
Plea
s
e
be
su
r
e
to
si
g
n
t
h
e
form
on
t
h
e
last
page.
457195
8172683
Prov
i
der’s
name
and
b
usi
n
ess
address:
_
_
_
___________
_
_____
_
_______
_
_______
_
_____
_
_
_
_____
_
________
457195
8494252
Type
o
f
practice
/
Medical
specialt
y
:
___
_
___
_
_______
_
_____
_
_______________
_
_____
_
_______
_
____
_
_
_
_
457195
8815310
Telepho
n
e:
(__
_
_____)_
_
___
_
_____
_
________________
Fa
x
:(_____
_
___)_____
_
___
_
_______
_
_____
_
_____
457200
9612350
Page
1
Form
WH-
3
8
0
-E
Revised
May
2015
6245225
520065
453389
1144270
731518
640078
PART
A:
ME
D
ICAL
F
ACTS
1.
A
p
proximate
date
co
n
dit
i
on
c
o
mme
n
ced:
_
___
_
____
_
___
_
__
_
_______
_
__
_
____
_
_____
_
____
_
____
_
_____
883818
1126021
Pr
o
b
a
b
l
e
d
u
ration
of
c
ondition:
_____
_
______
_
__________
_
__________
_
__________
_
__________
_
_____
883818
1448423
Mark
b
elow
a
s
ap
p
licab
l
e:
Was
the
pati
e
nt
admitted
for
an
o
v
ernight
stay
in
a
h
osp
i
tal,
h
ospice,
or
resi
d
enti
a
l
m
edical
c
are
f
a
cili
ty
?
_No
_Yes.
If
so,
dates
of
a
d
m
ission:
883919
2089870
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
_____
_
____
_
__
_
_______
_
__
_
______
_
___
_
______
_
___
_
__
_
__
883915
2411365
Date(
s
)
y
ou
treated
the
pat
i
ent
f
or
c
o
ndition:
883919
2732992
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883915
3053791
Will
the
patient
n
eed
to
have
trea
t
m
ent
visits
a
t
least
twice
p
er
y
e
ar
due
to
the
c
o
ndition?
_No
_
Yes.
883902
3375354
Was
m
e
dicat
io
n,
other
than
o
v
er-the-c
o
unter
medic
a
t
i
o
n
,
pre
s
cribe
d
?
No
_Yes.
883915
3696083
Was
the
p
ati
en
t
referr
e
d
to
oth
e
r
health
care
provi
d
er(s)
for
eva
l
uati
o
n
or
trea
t
m
ent
(
e.g.,
ph
y
sical
therapist
)
?
_
_No
_
_
Yes.
If
so,
state
the
n
a
ture
o
f
such
t
r
eatments
and
e
xpe
c
ted
d
ura
t
ion
o
f
t
r
eatment:
883919
4178494
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
731370
4500057
2.
I
s
t
he
me
dic
a
l
c
on
d
it
i
on
pre
g
na
n
c
y
?
_No
_
Y
es.
If
s
o,
ex
p
ect
e
d
d
eli
v
ery
dat
e
:
_
__
_
________________
731560
4820816
3.
Use
t
he
in
f
ormat
i
on
pro
v
ided
b
y
the
e
mplo
y
er
in
Section
I
to
answer
this
qu
e
stio
n
.
I
f
the
e
m
plo
y
er
f
ails
to
provide
a
li
s
t
of
the
e
m
ployee
’
s
esse
n
tial
f
unctio
n
s
or
a
job
d
e
scri
p
tion,
answer
the
s
e
qu
e
stio
n
s
ba
s
ed
u
p
on
the
e
mplo
y
ee’s
own
desc
rip
tion
of
his
/
her
j
ob
f
u
ncti
o
ns.
883873
5463313
Is
t
he
e
m
plo
y
ee
un
a
ble
to
perform
any
of
his/h
e
r
j
ob
f
un
c
tio
n
s
d
ue
to
the
co
n
dition:
_
No
Yes.
884013
5784825
If
s
o
,
i
d
entify
the
job
functions
the
e
m
pl
o
y
ee
is
unable
to
per
f
orm:
883919
6097971
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
731664
6419583
4.
Descri
b
e
other
relevant
medical
f
a
cts,
if
an
y
,
rel
a
ted
to
the
c
ondition
for
whi
c
h
the
e
m
plo
ye
e
seeks
le
a
ve
(such
m
edical
f
a
cts
may
in
c
lude
s
y
m
ptom
s
,
di
a
gnosi
s
,
or
any
regimen
of
cont
i
nuing
tre
a
t
m
e
n
t
su
c
h
as
t
he
use
of
spe
c
ializ
e
d
equipment):
883919
7061961
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883919
7382824
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883919
7704387
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883919
8025950
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883919
8346813
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883919
8668375
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
883919
8989938
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
____
_
_____
_
__
_
_______
_
__
_
______
_
___
_
__
_
_______
_
__
_
__
731552
9264541
Page
2
CONTINU
E
D
O
N
NE
X
T
P
AGE
F
or
m
WH-
38
0
-
E
R
e
vis
ed
M
a
y
20
15
731518
640078
PART
B:
AM
OUNT
OF
LEAVE
NE
E
DED
5.
Will
t
he
emplo
y
ee
be
i
ncapacita
t
ed
for
a
si
n
gle
conti
nu
ous
per
i
od
of
t
ime
due
to
h
is/her
medi
c
al
co
n
ditio
n
,
incl
u
ding
a
ny
time
for
t
rea
t
ment
and
rec
o
ver
y
?
_
N
o
_Yes.
1188732
1286801
If
s
o,
e
stimate
the
be
g
in
n
ing
and
e
nding
da
t
es
f
or
t
he
per
i
od
o
f
inca
p
ac
i
t
y
:
_______________________
731488
1608363
6.
Wi
l
l
the
em
plo
ye
e
ne
e
d
to
a
tte
n
d
fo
l
low-up
t
r
eatment
a
ppo
i
nt
m
ents
or
work
pa
r
t-t
i
m
e
or
on
a
r
e
duc
e
d
schedule
bec
a
use
of
the
emp
l
o
y
e
e
’s
m
e
d
ical
condi
t
ion?
_No
_Yes.
1188739
2089867
If
so,
are
the
t
rea
t
ments
o
r
the
reduced
number
of
h
o
urs
of
work
med
i
cally
nece
s
sary?
_No
_Yes.
1188719
2572229
Estimate
treat
m
ent
sch
e
dule,
if
any,
including
the
d
a
tes
of
any
scheduled
a
p
pointments
and
the
t
ime
requi
r
ed
f
o
r
each
app
o
intm
e
nt,
i
n
cluding
any
rec
o
very
pe
r
iod:
1188725
3053800
_
_
___
_
__
_
______
_
___
_
____
_
_____
_
____
_
_____
_
____
_
__
_
_______
_
__
_
______
_
___
_
______
_
___
_
_
1188719
3375295
Est
i
m
a
te
the
part-t
i
m
e
or
reduced
w
ork
sche
d
ule
the
e
m
plo
y
ee
ne
e
ds,
if
an
y
:
1189140
3696158
__
_
_______
hour
(
s)
p
er
d
a
y
;
__________
d
a
y
s
p
er
week
f
r
o
m
___________
_
_
t
hr
o
ugh
_
________
_
___
731469
4017726
7.
Will
the
con
d
ition
c
ause
e
p
isodic
flare-
u
ps
per
i
odically
p
rev
e
nting
the
e
m
ploy
e
e
fr
o
m
perf
or
m
ing
his
/
her
j
ob
func
t
ions?
_No
_
_Yes.
1188737
4505366
I
s
i
t
m
e
d
i
c
a
ll
y
n
e
c
e
ss
a
r
y
f
o
r
t
h
e
e
m
p
l
o
y
ee
t
o
b
e
a
b
s
e
n
t
f
r
o
m
w
o
r
k
d
u
r
i
n
g
t
h
e
f
l
a
r
e
-u
p
s
?
_
N
o
Y
e
s
.
I
f
so
,
e
x
p
l
a
i
n
:
1188725
5020547
_
_
___
_
__
_
______
_
___
_
____
_
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_
____
_
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_
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_
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1188725
5342110
_
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___
_
_
1188667
5662812
Based
up
o
n
the
pat
i
ent
’
s
medical
hist
o
ry
and
your
knowledge
of
the
medical
c
o
nditio
n
,
estimate
the
frequ
e
ncy
of
flare-ups
and
t
h
e
dura
t
ion
o
f
rela
t
ed
in
c
a
p
acity
that
the
p
a
tient
m
ay
have
o
v
er
the
n
e
xt
6
m
onths
(
e.g
.
,
1
e
pis
o
de
e
very
3
m
onths
l
ast
i
ng
1
-2
d
a
y
s):
801572
6305988
Fre
q
ue
n
cy
:
_
____
times
per
_____
w
e
ek
(
s)
_
____
m
on
t
h(s)
1645792
6626856
Dur
a
tio
n
:
_____
hours
or
___
d
a
y
(s)
per
epis
o
de
731416
6935723
ADDIT
I
O
N
AL
INFOR
M
ATION:
ID
E
NTIFY
QU
E
STION
NU
M
BER
WITH
YOUR
AD
D
ITIONAL
ANSWER.
731485
7414001
_
_
___
_
__
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______
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___
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____
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731485
7726356
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_
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_
____
731485
8039554
_
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731485
8352753
_
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731485
8665951
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_____
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__
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_
__
_
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_
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_
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_
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_
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_
____
731485
8979150
_
_
___
_
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_
______
_
___
_
____
_
_____
_
____
_
_____
_
____
_
__
_
_______
_
__
_
______
_
___
_
______
_
___
_
__
_
____
731496
9253873
Page
3
CONTINU
E
D
O
N
NE
X
T
P
AGE
F
or
m
W
H
-
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0
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is
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6591753
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______
Signature
o
f
Health
Care
Provid
e
r
Date
731301
7869879
PAPERW
OR
K
RED
U
CTI
O
N
ACT
N
O
TICE
A
N
D
PUBLIC
BU
R
DEN
STATE
M
E
N
T
If
s
u
b
m
itted,
it
is
mandatory
f
o
r
e
m
plo
y
ers
to
ret
a
in
a
c
opy
of
t
h
is
disc
lo
sure
i
n
the
i
r
r
e
cords
for
three
y
ears.
29
U.S.C.
§
2
61
6
;
29
C.F.R.
§
825.
5
00.
Persons
a
r
e
n
ot
required
to
resp
o
nd
to
this
c
o
ll
e
ction
of
infor
m
at
i
on
un
le
ss
it
displa
y
s
a
currently
valid
OMB
control
n
u
mber.
T
he
Depar
t
m
e
nt
of
L
abor
esti
m
a
t
es
t
h
at
i
t
w
i
l
l
take
an
avera
g
e
of
20
m
i
nut
e
s
for
respond
e
nts
to
c
o
m
p
l
ete
this
collection
of
info
r
m
ati
o
n,
including
the
t
i
m
e
f
o
r
reviewing
ins
t
ructions,
sear
c
h
ing
existing
da
t
a
sourc
e
s,
gath
e
ring
and
m
aint
a
ining
the
data
need
ed
,
and
c
o
m
pleti
n
g
a
n
d
revie
w
ing
the
co
l
lection
o
f
i
n
for
m
at
i
on.
I
f
y
ou
have
a
ny
c
o
mmen
t
s
rega
r
ding
this
burd
e
n
est
i
mate
or
a
ny
other
aspect
of
t
his
c
o
llecti
o
n
info
r
m
ation,
i
n
cludi
n
g
sug
ge
stio
n
s
for
r
educing
this
burden,
se
n
d
th
e
m
to
the
A
d
ministra
t
or,
W
age
and
Hour
Division,
U.S.
Dep
a
r
t
ment
of
Labor,
Ro
o
m
S
-
350
2
,
2
0
0
C
o
n
stitution
Ave
.
,
N
W
,
W
ashingto
n
,
D
C
20210.
DO
NOT
SEND
C
O
MPL
E
TED
F
ORM
TO
TH
E
DEPA
R
T
M
E
N
T
OF
LAB
O
R;
RETURN
TO
THE
PAT
IENT.
731515
9246265
Page
4
F
or
m
WH-
38
0
-
E
Re
v
is
ed
M
a
y
2
0
1
5
................
................
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