Fact Sheet #28G: Certification of a Serious Health - DOLFact Sheet #28G: Certification of a Serious 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the employee's name at the top of the form. If the patient's name differs, provide that information in the designated field.
3. Indicate your relationship to the employee in the corresponding section.
4. Select the nature of the serious health condition by checking one or more categories provided. Be sure to refer to definitions on the reverse side for clarity.
5. Provide a detailed description of medical facts supporting your certification, explaining how they meet selected criteria.
6. Fill in the approximate date when the patient’s condition began.
7. Answer whether the patient is presently incapacitated and provide details on duration and frequency if applicable.
8. Indicate if full-time leave is necessary, including effective dates if applicable.
9. If intermittent leave is needed, specify effective dates and frequency of absences.
10. Complete any additional sections regarding treatment regimens and assistance needs for family members, ensuring all fields are filled accurately.

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