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Certification for Serious Injury or Illness of a Current Service member for Military Family Leave (Family and Medical Leave Act)U.S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED

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How to fill out certification for serious injury

01

To fill out certification for serious injury, follow these steps:

02

Start by providing your personal information such as name, address, and contact details.

03

Clearly state the date and time of the injury.

04

Describe the nature of the injury in detail, including any visible signs or symptoms.

05

Mention any medical treatments or procedures received for the injury.

06

Include the names and contact information of any witnesses to the injury, if applicable.

07

If applicable, provide any supporting documents such as medical reports or receipts.

08

Sign and date the certification to declare the information provided is true and accurate.

Who needs certification for serious injury?

01

Certification for serious injury is usually required by individuals who have suffered a severe injury and need to provide documentation for legal or insurance purposes.

02

This may include individuals involved in workplace accidents, car accidents, personal injury lawsuits, or those seeking compensation for medical expenses related to the injury.

03

The certification serves as proof of the injury and the severity of its impact on the individual's health and well-being.

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What is certification for serious injury?

Certification for serious injury is a document confirming that a person has sustained a serious injury.

Who is required to file certification for serious injury?

Employers are required to file certification for serious injury on behalf of their employees.

How to fill out certification for serious injury?

Certification for serious injury can be filled out by providing details of the injury, employee information, and employer signatures.

What is the purpose of certification for serious injury?

The purpose of certification for serious injury is to report and document any serious injuries sustained by employees in the workplace.

What information must be reported on certification for serious injury?

Information such as the date of injury, nature of injury, employee name, and employer information must be reported on certification for serious injury.

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