Regulations of Connecticut State Agencies
(See 29 CFR ยง 825.306)
(a) For purposes of compliance with FMLA, the Department has developed Form DOL-FM1 for employees' (or their family members') use in obtaining medical certification, including second and third opinions, from health care providers that meets FMLA's certification requirements. This optional form reflects certification requirements so as to permit the health care provider to furnish appropriate medical information within his or her knowledge. A copy of the form is attached to sections 31-51qq-1 to 31-51qq-48, inclusive, of the Regulations of Connecticut State Agencies as Appendix A.
(b) Form DOL-FM1, or another form containing the same basic information, may be used by the employer; however, no additional information may be required. In all instances the information on the form must relate only to the serious health condition for which the current need for leave exists. The form identifies the health care provider and type of medical practice (including pertinent specialization, if any), makes maximum use of checklist entries for ease in completing the form, and contains required entries for:
(1) A certification as to which part of the definition of "serious health condition", if any, applies to the patient's condition, and the medical facts which support the certification, including a brief statement as to how the medical facts meet the criteria of the definition.
(2) The approximate date the serious health condition commenced, and its probable duration, including the probable duration of the patient's present incapacity (defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefor, or recovery therefrom) if different.
(3) Whether it shall be necessary for the employee to take leave intermittently or to work on a reduced leave schedule basis (i.e., part-time) as a result of the serious health condition, and if so, the probable duration of such schedule.
(4) If the condition is pregnancy or a chronic condition, whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity.
(5) If additional treatments shall be required for the condition, an estimate of the probable number of such treatments. If the patient's incapacity shall be intermittent, or shall require a reduced leave schedule, an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any.
(6) If any of the treatments referred to in subdivision (5) of this subsection shall be provided by another provider of health services (e.g., physical therapist), the nature of the treatments.
(7) If a regimen of continuing treatment by the patient is required under the supervision of the health care provider, a general description of the regimen.
(8) If medical leave is required for the employee's absence from work because of the employee's own condition (including absences due to pregnancy or a chronic condition), whether the employee:
(A) is unable to perform work of any kind;
(B) shall be absent from work for treatment.
(9) If leave is required to care for a family member of the employee with a serious health condition, whether the patient requires assistance for basic medical or personal needs or safety, or for transportation; or if not, whether the employee's presence to provide psychological comfort would be beneficial to the patient or assist in the patient's recovery. The employee shall indicate on the form the care he or she will provide and an estimate of the time period.
(10) If the employee's family member will need care only intermittently or on a reduced leave schedule basis (i.e., part-time), the probable duration of the need.
(c) If the employer's sick or medical leave plan requires less information to be furnished in medical certifications than the certification requirements of this section, and the employee or employer elects to substitute paid sick, vacation, personal or family leave for unpaid FMLA leave where authorized, only the employer's lesser sick leave certification requirements may be imposed.
(Adopted effective March 9, 1999)