Section One: FMLA Medical Certification Form for EMPLOYEE--Sudden Health Event

Sedgwick County Human Resources Contact: FMLA/ADA Specialist – 316.660.7056
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification completed by the employee’s health care provider. Sedgwick County maintains records and documents relating to medical certifications, and medical histories of employees created for FMLA purposes, as confidential medical records kept in a separate file from the employee’s personnel file.

INSTRUCTIONS: Sedgwick County policy 4.711 requires you to submit a timely, complete, and sufficient medical certification supporting your request for job protected absences due to your own serious health condition. Submission of this medical certification form is required by Sedgwick County in order to obtain and/or retain leave protections. Failure to provide complete and sufficient medical certification may result in the denial or delay of your FMLA request. You have 15 calendar days from the date you receive this form to return it to Sedgwick County – Division of Human Resources. DO NOT SUBMIT THIS FORM TO YOUR SUPERVISOR or another employee

Employee Information

First Name (required)

Middle Name

Last Name (required)

Cell Phone (required)

Personal (non-Sedgwick County) email address to access while on leave: (required)

Baby Bonding leave is continuous leave ONLY, beginning on the date of the emergent delivery/foster placement. If requesting time for baby bonding ahead of the event, submit your request in e-timesheet!!

I am requesting (required)

Continuous FML

Start Date (required)

Expected End Date

Acknowledgments: (required)

I hereby consent for my health care provider to release information to Sedgwick County Human Resources regarding my health condition.

I hereby provide my consent for Sedgwick County Human Resources to contact my health care provider to clarify and/or to authenticate any information provided on this form.

I understand that it is my responsibility to ensure that my health care provider completes Section Two of the Medical Certification from Health Care Provider Form and returns it to Sedgwick County Human Resources within 15 calendar days of this submission.

Employee Signature (required)

Date (required)