"Certification of Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)" - Delaware

Certification of Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act) is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

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State of Delaware
Department of Human Resources
Certification of Serious Injury or Illness of a Veteran
for Military Caregiver Leave (Family and Medical Leave Act)
Authority: The Family and Medical Leave Act
Policy #: To be assigned.
of 1993, as amended February 25, 2015; M.R. 5.7
Effective Date: November 20, 2019
Supersedes: March 2013
Notice to the EMPLOYER
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military caregiver
leave under the FMLA leave due to a serious injury or illness of a covered veteran to submit a certification providing
sufficient facts to support the request for leave. Your response is voluntary. While you are not required to use this form, you
may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310.
Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical
histories of employees or employees’ family members, created for FMLA purposes as confidential medical records in
separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with
Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act
applies.
SECTION I: For completion by the EMPLOYEE and/or the VETERAN for whom the employee is
requesting leave
INSTRUCTIONS to the EMPLOYEE and/or VETERAN:
Please complete Section I before having Section II
completed. The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification
to support a request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If
requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. (29 U.S.C. §§ 2613,
2614(c)(3)) Failure to do so may result in a denial of an employee’s FMLA request. (29 C.F.R. § 825.310(f)) The employer
must give an employee at least 15 calendar days to return this form to the employer.
(This section must be completed before Section II can be completed by a health care provider.)
Part A: EMPLOYEE INFORMATION
Name and address of employer (this is the employer of the employee requesting leave to care for a veteran):
Name of employee requesting leave to care for a veteran:
First
Middle
Last
Name of veteran (for whom employee is requesting leave):
First
Middle
Last
Relationship of employee to veteran:
Spouse
Parent
Son
Daughter
Next of Kin
(please specify relationship):
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State of Delaware
Department of Human Resources
Certification of Serious Injury or Illness of a Veteran
for Military Caregiver Leave (Family and Medical Leave Act)
Authority: The Family and Medical Leave Act
Policy #: To be assigned.
of 1993, as amended February 25, 2015; M.R. 5.7
Effective Date: November 20, 2019
Supersedes: March 2013
Notice to the EMPLOYER
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military caregiver
leave under the FMLA leave due to a serious injury or illness of a covered veteran to submit a certification providing
sufficient facts to support the request for leave. Your response is voluntary. While you are not required to use this form, you
may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310.
Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical
histories of employees or employees’ family members, created for FMLA purposes as confidential medical records in
separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with
Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act
applies.
SECTION I: For completion by the EMPLOYEE and/or the VETERAN for whom the employee is
requesting leave
INSTRUCTIONS to the EMPLOYEE and/or VETERAN:
Please complete Section I before having Section II
completed. The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification
to support a request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If
requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. (29 U.S.C. §§ 2613,
2614(c)(3)) Failure to do so may result in a denial of an employee’s FMLA request. (29 C.F.R. § 825.310(f)) The employer
must give an employee at least 15 calendar days to return this form to the employer.
(This section must be completed before Section II can be completed by a health care provider.)
Part A: EMPLOYEE INFORMATION
Name and address of employer (this is the employer of the employee requesting leave to care for a veteran):
Name of employee requesting leave to care for a veteran:
First
Middle
Last
Name of veteran (for whom employee is requesting leave):
First
Middle
Last
Relationship of employee to veteran:
Spouse
Parent
Son
Daughter
Next of Kin
(please specify relationship):
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Policy #: To be assigned.
Certification for Serious Injury or Illness of a Veteran for
Rev. Date:
Military Caregiver Leave (Family and Medical Leave Act)
Part B: VETERAN INFORMATION
(1)
Date of the veteran’s discharge:
(2)
Was the veteran dishonorably discharged or released from the Armed Forces (including the National Guard
or Reserves)? Yes
No
(3)
Please provide the veteran’s military branch, rank and unit at the time of discharge:
(4)
Is the veteran receiving medical treatment, recuperation, or therapy for an injury or illness?
Yes
No
Part C: CARE TO BE PROVIDED TO THE VETERAN
Describe the care to be provided to the veteran and an estimate of the leave needed to provide the care:
SECTION II: For completion by: (1) a United States Department of Defense (“DOD”) health care provider; (2) a
United States Department of Veterans Affairs (“VA”) health care provider; (3) a DOD TRICARE network
authorized private health care provider; (4) a DOD non-network TRICARE authorized private health care
provider; or (5) a health care provider as defined in 29 C.F.R. § 825.125.
INSTRUCTIONS to the HEALTH CARE PROVIDER:
The employee named in Section I has requested leave under the
military caregiver leave provision of the FMLA to care for a family member who is a veteran. For purposes of FMLA military
caregiver leave, a serious injury or illness means an injury or illness incurred by the servicemember in the line of duty on active duty in
the Armed Forces (or that existed before the beginning of the servicemember’s active duty and was aggravated by service in the line
of duty on active duty in the Armed Forces) and manifested itself before or after the servicemember became a veteran, and is:
(i)
a continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a
member of the Armed Forces and rendered the servicemember unable to perform the duties of the servicemember’s office,
grade, rank, or rating; or
(ii)
a physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs
Service Related Disability Rating (VASRD) of 50 percent or greater, and such VASRD rating is based, in whole or in part,
on the condition precipitating the need for military caregiver leave; or
(iii)
a physical or mental condition that substantially impairs the covered veteran’s ability to secure or follow a
substantially gainful occupation by reason of a disability or disabilities related to military service, or would do so absent
treatment; or
(iv)
an injury, including a psychological injury, on the basis of which the covered veteran has been enrolled in the
Department of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
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Policy #: To be assigned.
Certification for Serious Injury or Illness of a Veteran for
Rev. Date:
Military Caregiver Leave (Family and Medical Leave Act)
A complete and sufficient certification to support a request for FMLA military caregiver leave due to a covered veteran’s
serious injury or illness includes written documentation confirming that the veteran’s injury or illness was incurred in the line
of duty on active duty or existed before the beginning of the veteran’s active duty and was aggravated by service in the line of
duty on active duty, and that the veteran is undergoing treatment, recuperation, or therapy for such injury or illness by a health
care provider listed above. Answer fully and completely all applicable parts. Several questions seek a response as to the
frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical
knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or
“indeterminate” may not be sufficient to determine FMLA military caregiver leave coverage. Limit your responses to the
veteran’s condition for which the employee is seeking leave. Do not provide information about genetic tests, as defined in 29
C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e).
(Please ensure that Section I has been completed before completing this section. Please be sure to sign the form on
the last page and return this form to the employee requesting leave (See Section I, Part A above).
DO NOT SEND
)
THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION.
Part A: HEALTH CARE PROVIDER INFORMATION
Health care provider’s name and business address:
Telephone:
Fax:
Email:
Type of Practice/Medical Specialty:
Please indicate if you are:
a DOD health care provider
a VA health care provider
a DOD TRICARE network authorized private health care provider
a DOD non-network TRICARE authorized private health care provider
other health care provider
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Certification for Serious Injury or Illness of a Veteran for
Policy #: To be assigned.
Military Caregiver Leave (Family and Medical Leave Act)
Rev. Date:
PART B: MEDICAL STATUS
Note: If you are unable to make certain of the military-related determinations contained in Part B, you are
permitted to rely upon determinations from an authorized DOD representative (such as DOD Recovery Care
Coordinator) or an authorized VA representative.
(1)
The Veteran’s medical condition is:
A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran
was a member of the Armed Forces and rendered the servicemember unable to perform the duties of the
servicemember’s office, grade, rank, or rating.
A physical or mental condition for which the covered veteran has received a U.S. Department of
Veterans Affairs Service Related Disability Rating (VASRD) of 50% or higher, and such VASRD rating is
based, in whole or in part, on the condition precipitating the need for military caregiver leave.
A physical or mental condition that substantially impairs the covered veteran’s ability to secure or
follow a substantially gainful occupation by reason of a disability or disabilities related to military
service, or would do so absent treatment.
veteran is enrolled in the
An injury, including a psychological injury, on the basis of which the covered
Department of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
None of the above.
(2)
Is the veteran being treated for a condition which was incurred or aggravated by service in the line of duty
on active duty in the Armed Forces? Yes
No
(3)
Approximate date condition commenced:
(4)
Probable duration of condition and/or need for care:
(5)
Is the veteran undergoing medical treatment, recuperation, or therapy for this condition? Yes
No
If yes, please describe medical treatment, recuperation or therapy:
PART C: VETERAN’S NEED FOR CARE BY FAMILY MEMBER
“Need for care” encompasses both physical and psychological care. It includes situations where, for example, due to
his or her serious injury or illness, the veteran is unable to care for his or her own basic medical, hygienic, or
nutritional needs or safety, or is unable to transport himself or herself to the doctor. It also includes providing
psychological comfort and reassurance which would be beneficial to the veteran who is receiving inpatient or home
care.
(1)
Will the veteran need care for a single continuous period of time, including any time for treatment and
recovery? Yes
No
If yes, estimate the beginning and ending dates for this period of time:
(2)
Will the veteran require periodic follow-up treatment appointments? Yes
No
If yes, estimate the treatment schedule:
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Certification for Serious Injury or Illness of a Veteran for
Policy #: To be assigned.
Military Caregiver Leave (Family and Medical Leave Act)
Rev. Date:
(3)
Is there a medical necessity for the veteran to have periodic care for these follow-up treatment appointments?
Yes
No
(4)
Is there a medical necessity for the veteran to have periodic care for other than scheduled follow-up treatment
appointments (e.g., episodic flare-ups of medical condition)?
Yes
No
If yes, please estimate the frequency and duration of the periodic care:
Signature of Health Care Provider:
Date:
PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, in accordance with 29
U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents
to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding
this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to
the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, DC
20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE
PATIENT.
Notification to Healthcare Providers
Title II of the Genetic Information Nondiscrimination Act (GINA) “prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of employees or their family
members. In order 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 test, the fact that
an individual or an individual’s family member sought or received 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.”
Additional Notification Relating to Pregnancy and Employment:
Employees, as defined in SB 212, shall be free from discrimination in relation to pregnancy, childbirth, and
related conditions, including the right to reasonable accommodation to known limitations related to pregnancy,
childbirth and related conditions pursuant to Title 19 of the Delaware Code, Chapter 7. See 19 Delaware Code
Section 711(a)(3).
For Agency Use Only
Date Issued to Employee:
Date Returned by Employee:
Date Approved:
Date Denied:
Date Returned to Employee for
additional information:
Reviewed by:
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