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Certification of Health Care Provider for Employees Serious Health Condition (Family and Medical Leave Act)U.S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED FORM TO THE DEPARTMENT
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How to fill out certification for serious injury

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How to fill out certification for serious injury

01
Start by providing your personal information such as your name, address, and contact details.
02
Include the details of the serious injury, such as the date, time, and location of the incident.
03
Describe the nature of the serious injury and how it occurred.
04
Attach any relevant medical records or documents to support the certification.
05
Provide the name and contact information of any witnesses who can corroborate the injury.
06
Sign and date the certification to verify its accuracy.
07
Submit the filled-out certification to the relevant authority or organization.

Who needs certification for serious injury?

01
Anyone who has suffered a serious injury and requires documentation to support their claim or legal proceedings.
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Certification for serious injury is a form or document that confirms an individual has sustained a serious injury.
Employers or individuals who are responsible for reporting workplace injuries are required to file certification for serious injury.
Certification for serious injury should be filled out completely and accurately, including details about the injury, the individual affected, and the circumstances surrounding the injury.
The purpose of certification for serious injury is to document and verify that a serious injury has occurred in the workplace, and to ensure that appropriate actions are taken to address the injury and prevent future occurrences.
Information that must be reported on certification for serious injury includes details about the injury, the individual affected, the date and time of the injury, the location where the injury occurred, and any witnesses to the injury.
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