TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

Certification of Health Care Provider for

Employee’s Serious Health Condition LOA Due to Covid-19

Employer Name: ____________________________________________________________________________

Phone Number: 	

Employee’s Job Title:	

Work Site/Location: ____________________________________________________________

Employee’s essential job functions: 	

Check if job description is attached:

SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. Teaneck Public Schools requires that you submit a timely, complete, and sufficient medical certification to support a request emergency paid sick leave as provided under the Families First Coronavirus Response Act or request to work remotely as a result of your compromising medical condition. Failure to provide a complete and sufficient medical certification may result in a denial of your request.

Your name: 		_____________________ First                                   Middle	Last

SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested emergency paid sick leave as provided under the Families First Coronavirus Response Act or request to work remotely as a result of his/her compromising medical condition. 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 coverage. Limit your responses to the 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), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29 C.F.R. § 1635.3(b). Please be sure to sign the form on the last page.

Provider’s name and business address: 	

Type of practice / Medical specialty:

Telephone: (	)	Fax:(	)	

TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

PART A: MEDICAL FACTS

1. Approximate date condition commenced: 	

Probable duration of condition: 	

Mark below as applicable:

In accordance with Governor Murphy’s Restart and Recovery Plan for Education - Reasonable
accommodations should be provided for individuals that the Centers for Disease Control identifies as having a 
higher risk for severe illness from COVID-19, including older adults (aged 65 years and older) and individuals with disabilities or serious underlying medical conditions, which include:

Check all that apply:
____	Chronic lung disease or asthma (moderate to severe) ____	Serious heart conditions
____	Immunocompromised
____	Severe obesity (body mass index, or BMI, of 40 or higher) ____	Diabetes
____	Chronic kidney disease undergoing dialysis ____	Liver disease
____	Other

Has the patient tested positive for Coronavirus (Covid-19)? Yes ______ No ________

Date test was conducted ________________

Date results were known _______________

In your professional medical opinion, can the patient work in their Teaneck Public School work site if all CDC guidelines are followed and enforced, thus providing the staff member with safe working conditions?

__________Yes	______ No, explain

Will the patient need to have regular treatment due tothe condition?	No_____ Yes _____

Was medication, other than over the counter medication, prescribed?	No	Yes.

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., specialist)? _ _No _ _Yes. If so, state the nature of such treatments and expected duration of treatment:

2. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the employee’s essential functions or a job description, answer these questions based upon

Page 4

TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

the employee’s own description of his/her job functions.

Is the employee unable to perform any of his/her job functions due tothe condition: _	No	Yes.

If so, identify the job functions the employee is unable to perform:

3. Describe other relevant medical facts, if any, related to the condition for which the employee seeks to take a leave of absence (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as theuse of specialized equipment):

PART B: AMOUNT OF LEAVE NEEDED
4. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery?	_No	_Yes.

If so, estimate the beginning and ending dates for the period ofincapacity: 	

5. Will the employee need to attend follow-up treatment appointments or work part-time or on areduced schedule because of the employee’s medical condition?	_No	_Yes.

If so, are the treatments or the reduced number of hours of work medically necessary? _No	_Yes.

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

Estimate the part-time or reduced work schedule the employee needs, if any:

	hour(s) per day;	days per week from	through 	

6. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions?	No _	Yes.

Is it medically necessary for the employee to be absent from work during the flare-ups? ____ No ____Yes If so,explain:

Page 5

TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):

Frequency	:	times per	week(s)	month(s)

Duration:	hours or	day(s) per episode

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL
	
ANSWER.

Page 6

TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

Signature of Health Care Provider	Date

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 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 Ave., NW, Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

Page 7