Purpose:

To be given to the faculty/staff member and completed by his/her health care provider to support the request for leave.

Who:

Supervisor responsibility to provide form to faculty/staff member with the "Vanderbilt Notification of FMLA Status" form. Form is available on the HR web page.

When:

This form is provided with the "Vanderbilt Notification of FMLA Status" form. The faculty/staff member is required to provide medical certification within 15 days. If the form is not returned within 15 days, the supervisor should immediately contact Employee Relations for appropriate next steps.

NOTE: The medical certification should be immediately forwarded to Occupational Health for FMLA-qualifying event determination. Certification should never be retained in department files.

Complete:  

Form to be completed by health care provider. Form is signed by health care provider or faculty/staff member (for FMLA leave to care for a family member). For additional information on the completion of this form, please call Occupational Health or Employee Relations.

NOTE: If the supervisor needs clarification or authentication of a medical certification, contact Occupational Health or Employee Relations to have a VU health care provider contact the faculty/staff member’s health care provider. Supervisors may not contact the faculty/staff member’s health care provider directly.