(Family and Medical Leave Act, as made applicable by the Congressional Accountability Act)

INSTRUCTIONS to the EMPLOYING OFFICE: The Family and Medical Leave Act (FMLA), as made applicable by the Congressional Accountability Act (CAA), provides that an employing office may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider.

Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations issued by the Office of Congressional Workplace Rights (OCWR) Board of Directors at 825.306-825.308. Employing offices must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files, if the Americans with Disabilities Act and/ or the Genetic Information Nondiscrimination Act apply, as made applicable by the CAA.