An employee’s leave request to care for the employee’s own serious health condition or that of a seriously ill family member (child, parent, or spouse, spousal equivalent) must be supported by a certification issued by the employee’s or ill family member’s healthcare provider. Certification must be furnished prior to commencement of leave and every 30 days thereafter. Failure to provide requested information in a timely manner may result in the delay or denial of FMLA leave.

Note: The definition of healthcare provider for unpaid FMLA leave is different from MIT’s paid sick leave policy. To receive paid leave benefits under MIT sick leave policy, the employee must provide a certification completed and signed by a legally qualified physician.

See a chart of acceptable healthcare providers signatures for FMLA and Extended Sick Leave medical certifications.

Medical certification for FMLA leave purposes must state the following:

• The date on which the serious health condition commenced;

• The probable duration of the condition;

• The appropriate medical facts within knowledge of the health care provider regarding the condition

• For leaves taken to care for a serious health condition of an ill family member, a statement that the eligible employee is needed to care for the family member and an estimate of the amount of time that such employee is needed to care for the family member.

• For leaves taken to care for the employee’s own serious health condition, a statement that the employee is unable to perform the essential functions of his or her position.

• For intermittent or reduced schedule leaves:
  • A statement of the medical necessity for the intermittent or reduced schedule leave
  • A statement on the duration of the intermittent or reduced schedule leave.
  • For planned treatments, the dates on which such treatment is expected to be given and the duration of such treatment.
  • For leaves taken to care for a serious health condition of an ill family member, a statement that the employee’s intermittent or reduced schedule leave is necessary for the care of such family member who has a serious health condition or the employee will assist in their recovery.

Forms
The form below is in Microsoft Word. You may open it directly to print, or save it locally to your computer before printing.

• Download the MIT Medical Certification form (Adobe PDF)