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Get SIUE FMLA Medical Certification: Family Member 2019

The EMPLOYEE and/or the COVERED SERVICE MEMBER for whom the employee is requesting leave. Please complete this section before giving this form to your family member or his/her medical provider. PART A: EMPLOYEE INFORMATION Banner ID: 800 Employee s Name (Last, First): Information of family member for whom employee is requesting leave to care: Relationship: Name: If family member is employee's son or daughter, Date of Birth: Describe care that will be provided to family member by employee a.

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