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The document is a Certification of Health Care Provider form (Form 16874) used by Union Pacific Railroad for employees requesting leave under the Family and Medical Leave Act (FMLA). It requires employees to provide personal information, the reason for leave, and details about their health condition or that of a family member. The form must be completed by both the employee and their healthcare provider, who must certify the medical necessity for the leave. It outlines the responsibilities of both parties in providing sufficient medical certification to support the FMLA request.

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Which doctor should fill out FMLA paperwork?

Completed certification forms should be given to the employee to provide to the employer, as it is the employees responsibility to provide the employer with the completed certification.

Who typically requests a fitness for duty evaluation?

A doctor of medicine or osteopathy who is authorized to practice medicine or surgery (as appropriate) by the State in which the doctor practices; or. Any other person determined by the Secretary to be capable of providing health care services.

What is the difference between MLOA and FMLA?

A Medical Leave of Absence (MLOA) is intended for those who do not qualify for FMLA or have exhausted their FMLA time. MLOA can only be used for your personal injury or illness, and is not job protected.

Who fills out the fitness for duty form?

The employee is required to provide a complete and sufficient Fitness for Duty Certification, completed by his or her health care provider, prior to returning to work from FMLA leave. This certification is being sought only with regard to the particular health condition that caused the employees need for FMLA leave.

What forms does an employee need to fill out for FMLA?

While use of this form is optional, a fully completed Form WH- 381 provides employees with the information required by 29 C.F.R. 825.300(b), (c) which must be provided within five business days of the employee notifying the employer of the need for FMLA leave.