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Get UT Family’s Serious Health Condition Form - Salt Lake County 2017-2024

By Agency This form is confidential. Agency must maintain documents relating to medical certifications, recertifications or medical histories of employees created for FMLA as confidential medical records in a file separate from the personnel file. Agency Contact Person and phone/email: SECTION II: To be completed by Employee You must submit this form to the Agency contact person listed above within 15 calendar days. Your Name: Last Name First Name Middle Name/Initial Name of family member for.

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