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The Department of Family and Medical Leave (DFML) will review all applications to determine your eligibility for benefits. Both the employee whois applying for leave and a health care provider must complete a portion of this certification. This certification will be shared with DFML and your employer* .  \nThis form is required for...  \n Medical leave  \ndue to your own serious health condition.  \n Family leave  \nto care for a family member with a serious health condition related to military service.  \nStarts Jan. 1, 2021 Starts Jan. 1, 2021  \n Family leave  \nto care for a family member with any other serious health condition.  \nStarts Jul. 1, 2021  \nThis form is not required for...  \n Parental leave  \nto bond with a child  \n12 months after birth, adoption, or foster careplacement.  \n Active duty leave  \nto manage family affairs when a family member is in the armed forces.  \nStarts Jan. 1, 2021 Starts Jan. 1, 2021  \nHow to use this form  \n*The information you provide to DFML on this form will be used to administer PFML benefits. In order to process your claim application, and determine your eligibility and benefit amount, DFML shares your information with your current and/or past employer(s), and DFML State [Partners. Visit](Partners. Visit Mass.gov/DFML or)[ Mass.gov/DFML](Partners. Visit Mass.gov/DFML or)[ or](Partners. Visit Mass.gov/DFML or) call our Contact Center at 833-344-7365 for more information.  \nQuestions?  \nContact us at (833) 344-PFML (7365) [or find us online at](or find us online at Mass.gov/DFML)[ Mass.gov/DFML](or find us online at Mass.gov/DFML).  \nPFML-FORM-0001-Cert-SHC-V1 .0.2, December 2020  \n1  \nEmployee Applying for Paid Leave  \nInstructions ► The person applying for paid leave from their own job isthe employee. Asthe employee, complete this section with your own information. The Department of Family and Medical Leave will use Section 1 to match this certification to the rest of your application for paid leave.  \n1 Your name: First Last  \n2 (If different) Your name as it appears on official documents like a driver’s license or W-2:  \nFirst Middle Last  \nPhone \\#: (   |  |  ) -|  |  |  |-|  |  |  |  |  \n5 Gender identity:  Woman  Man  Nonbinary  Gender not listed  \n6 Last 4 digits of your Social Security Number or Individual Taxpayer ID Number (ITIN):  \n7 Why are you applying for leave?  \n My own serious health condition  \n A family member’s serious health condition that is related to military service  \n A family member’s serious health condition of any other kind  \n|  \n8  \nOccupation:  \n9  \nIf you are applying for your own serious health condition, describe your job’s physical exertion level.  \n  1 Sedentary   2 Light   3 Medium  \n 4 Heavy  5 Very Heavy  N/A  \n◄  \nCheck only one. Refer to the definitions below.  \nLevels of exertion  \n 1 Sedentary  \nSitting most of the time. Exerting up to 10 pounds of force occasionally to move objects; or a negligible amount of force frequently.  \nE.g., Dispatcher, Receptionist  \n 2 Light  \nWalking or standing frequently, using physical controls while sitting or driving, or working at a production rate pace with lighter materials (e.g., clothing) . Exerting up to 20 pounds of force occasionally; or up to 10 pounds of force frequently. E.g., Textile worker, Grocery stocker, Passenger vehicle driver  \n 3 Medium  \nExerting 20–50 pounds of force occasionally; 10–25 pounds of force frequently; or up to 10 pounds constantly. E.g., Plumber, Electrician  \n 4 Heavy  \nExerting 50 to 100 pounds of force occasionally; 25–50 pounds of force frequently; or 10–20 pounds constantly.  \nE.g., Construction, Delivery driver  \n 5 Very heavy  \nExerting over 100 pounds of force occasionally; over 50 pounds of force frequently; or more than 20 pounds of force constantly. E.g., The heaviest construction jobs  \nQuestions?  \nContact us at (833) 344-PFML (73","cbCaidyKbiZ7gARy","https://ap.wps.com/l/cbCaidyKbiZ7gARy","pdf",1243843,9,"English","# Employee Applying for Paid Leave\n## Why are you applying for leave?\n## Occupation and physical exertion level\n# Patient Information\n## Relationship to the patient\n## Patient identifying information\n# Health Care Provider Instructions\n## Definition of a serious health condition","[{\"question\":\"Who must complete parts of the certification form for Massachusetts PFML?\",\"answer\":\"Both the employee applying for leave and a health care provider must complete portions of the certification. DFML uses the completed form to determine eligibility for benefits.\"},{\"question\":\"What types of leave does the form cover for serious health conditions?\",\"answer\":\"The form covers medical leave for the employee’s own serious health condition and family leave to care for a family member with a serious health condition, including conditions related to military service and other serious conditions.\"},{\"question\":\"How is the employee’s work physical exertion level documented?\",\"answer\":\"In the employee section, the applicant selects one exertion level (sedentary, light, medium, heavy, very heavy, or N/A) and follows the provided definitions to describe the physical exertion level of their job.\"}]","Certification of a Serious Health Condition - Form | PDF",1789828387]