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Certification of Health Care Provider for Employees Serious Health Condition (Family and Medical Leave Act) SECTION 1: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete
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Section 1 is the initial part of a form that requires basic information from the individual.
The individual or employee is required to fill out section 1 for completion.
Section 1 should be completed by providing personal information such as name, address, date of birth, etc.
The purpose of section 1 is to gather necessary information from the individual for documentation.
Information such as name, address, date of birth, citizenship status, and social security number must be reported on section 1.
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