Get Dol Fm1 Form

Filling out the Dol Fm1 Form online is an important process for employers subject to the Connecticut Family and Medical Leave Act. This guide provides clear and user-friendly instructions tailored to assist you in completing the form accurately and efficiently.

Follow the steps to complete the Dol Fm1 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing format.
2. Begin by filling in the employee’s name in the designated field.
3. If the patient is different from the employee, enter the patient's name in the appropriate section.
4. Determine if the patient’s condition qualifies as a serious health condition. Check one of the categories listed or indicate 'none of the above' if applicable.
5. In the section provided, describe the medical facts that support your certification and explain how these facts fit into one of the defined categories.
6. a. State the approximate date the condition began and its expected duration; b. Indicate if the employee will need to work intermittently or on a reduced schedule because of the condition; c. If chronic or related to pregnancy, detail the current incapacity status and frequency.
7. If further treatments are needed, estimate the number of treatments required. Include details on the frequency and location of these treatments.
8. For conditions requiring a regimen of continuing treatment, describe the nature of these treatments.
9. When addressing the employee’s own condition, state if they are unable to perform any work or if they need to be absent for treatment.
10. For care of a family member, confirm if the patient needs help with basic needs or safety. If care is needed intermittently, provide expected duration.
11. Complete the signature section of the form, ensuring both the health care provider and the employee include their signatures and dates.
12. Once all sections are filled out, review for accuracy and completeness before saving changes, and decide whether to download, print, or share the completed form.

Start completing your Dol Fm1 Form online today for a smoother submission process.