DNR SOP –HR608 Attachment #4
Certification of Childbirth, Adoption or Foster Care
(Family and Medical Leave Act)
The Family and Medical Leave Act (FMLA) permits the Georgia Department of Natural Resources to require that you submit a timely, complete and sufficient medical certification to support a request for Family and Medical Leave (FML) due to the birth of a child, adoption, or foster care. Your response is required to obtain or retain the benefit of FMLA protections. Failure to provide a complete and sufficient certification may result in a denial of your FML request. You must return this form within 15 calendar days of the date listed in the Rights and Responsibilities section of Attachment 2 (enclosed).
Employee Name:
EmployeeID:
Name of Mother: (if not employee)
Type of Leave Requested: I am requesting Family and Medical Leave(check one)
Without pay
With pay. Since I am requesting FML with pay, I am requesting to use the following type(s) of leave (check all that apply) Holiday Deferral FLSA Compensatory State Compensatory
AnnualSick Personal
Complete Applicable Section Below:
Note: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of employees or their family members. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic Information’ as defined by GINA includes an individual’s or an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive servicesand the manifestation of disease or disorder in the employee’s family members.
Birth:
This is to certify that the mother named above is expected to give birth on (date): / /
This is to certify that the mother named above gave birth on (date): / /
It is anticipated that the mother will be unable to work from: / / to / /
She should be able to return to work on (date): / /
Print or type name of Physician: ______M.D.
Signature of Physician:______Date:______
(No Stamps)
Adoption/Foster Care:
This is to certify that a child will be placed for adoption/foster care with the employee named above on / /
(Date)
This is to certify that a child was placed for adoption/foster care on / /
(Date)
______(Print/Type Name of Attorney; or Licensed Adoption/Forster Care Representative)
______
(Signature of Attorney; or Licensed Adoption/Foster Care Representative)Date
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