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

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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