FMLA Return to work Certification Form | Sedgwick County, Kansas

Employee Name (required)

ID#

Department

I certify that I will resume performing the functions of my position on the following date and have notified my supervisor. (required)

Returning from: (required)

Employee’s Continuous Medical Leave (Additional medical documentation required, contact HR)

Continuous Leave for covered family member (Includes returning from Baby Bonding Leave)

Employee Signature (required)

Date (required)