ONTARIO’S EMPLOYMENT STANDARDS ACT, 2000 Medical Certificate to Support Entitlement to Family Caregiver Leave, Family Medical Leave, and/or Critically Ill Child Care Leave
Medical Certificate – Introduction
Ontario’s Employment Standards Act, 2000 (“the ESA”) provides eligible employees the right to take unpaid leaves of absence from their job for certain reasons. These leaves include:
Family Caregiver Leave: available as of October 29, 2014 to employees to provide care or support tocertain individuals who have a serious medical condition.
Family Medical Leave: available to employees to provide care or support to certain individuals whohave a serious medical condition with a significant risk of death within a period of 26 weeks.
Critically Ill Child Care Leave: available as of October 29, 2014 to employees to provide care orsupport to a critically ill child.
In some cases, the illness of a single individual may entitle an employee to more than one of these leaves.
In order for an employee to be eligible for these leaves, a qualified health practitioner must issue a certificate verifying that certain conditions have been met. The conditions that must be met are different for each leave.
This form of certificate has been designed by the Ontario Ministry of Labour to provide a convenient way for the health practitioner to indicate whether the necessary conditions have been met. Note, however, that nothing in the ESA requires that a health practitioner use this particular form of certificate; any form of certificate that indicates that the necessary conditions have been met can be used.
Note: A certificate for entitlement to family medical leave can be issued only by a person qualified to practice medicine.
A certificate for entitlement to family caregiver leave or critically ill child care leave can be issued by a person qualified to practice medicine or a person qualified to practice as a registered nurse or a psychologist.
Employees:
The eligibility criteria, the individuals for whom a leave may be taken, the length and timing of a leave,the types of health care professionals who may complete the medical certificate, and otherrequirements for each type of leave are different. Please visit the Ontario Ministry of Labour’s websiteat Ontario.ca/employmentstandards, or call the Employment Standards Information Centre at 416-326-7160, toll-free at 1-800-531-5551 or TTY at 1-866-567-8893 for information.
An employer is entitled to ask you for a copy of the certificate of the qualified health practitioner toprovide proof that you are eligible for a leave or leaves. You are required to provide the copy as soonas possible after the employer requests it.
If you want to access Employment Insurance benefits for parents of critically ill children orcompassionate care benefits for family medical leave, you should visit Service Canada’s website at:http://www.servicecanada.gc.ca, or contact Service Canada’s Employment Insurance AutomatedTelephone Information Service at 1-800-206-7218. Service Canada has its own medical certificatesthat you must complete in order to be eligible to receive benefits.
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ONTARIO’S EMPLOYMENT STANDARDS ACT, 2000
Medical Certificate to Support Entitlement to Family Caregiver Leave, Family
Medical Leave, and/or Critically Ill Child Care Leave
Patient’s Name
I examined the patient on (YYYY/MM/DD)
A1. Does the patient have a serious medical condition? (This may include a condition that is chronic or
episodic.) Yes □ No □
A2. In some situations, the employee will have taken leave before this certificate is issued. Did the patient
have a serious medical condition before today? Yes □ No □
If yes, please provide the earlier date (YYYY/MM/DD)
A3. The patient is expected to have the serious medical condition until (YYYY/MM/DD) _______________
B1. Does the patient have a serious medical condition with a significant risk of death occurring within 26
weeks? Yes □ No □
B2. In some situations, the employee will have taken leave before this certificate is issued. Did the patient
have a serious medical condition with a significant risk of death occurring within a period of 26 weeks
before today? Yes □ No □
If yes, please provide the earlier date (YYYY/MM/DD)
C1. Patient’s Date of Birth (YYYY/MM/DD)
C2. Has the patient’s baseline state of health significantly changed? Yes □ No □
C3. Is the patient’s life at risk as a result of an illness or injury? Yes □ No □
C4. Does the patient require the care or support of a parent? Yes □ No □
C5. The patient is expected to require the care or support* of a parent until (YYYY/MM/DD)
and certify that the following conditions existed (check all that apply).
A. Family Caregiver Leave
B. Family Medical Leave
C. Critically Ill Child Care Leave
*Care or support includes directly providing or participating in the care of the patient; providing psychological or emotional support forthe patient; and arranging for the care of the patient by a third party care provider.
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C6. In some situations, the employee will have taken leave before this certificate is issued. Did all of the
conditions in C2 through C5 exist before today? Yes □ No □
If yes, please provide the earlier date (YYYY/MM/DD)
Signature of health practitioner
Date (YYYY/MM/DD)
Name
Address (street number and name)
City or Town
Province / Territory
Area Code and Telephone Number
Country
Postal Code / Zip Code (if in Canada or U.S.)
□ I am qualified to practise medicine
□ I am qualified to practise as a registered nurse
□ I am qualified to practise as a psychologist
License Number
Information of Health Practitioner Who Issues this Form:
*Note: Registered nurses and psychologists are not eligible to issue certificates in support of Family MedicalLeave for purposes of the Ontario Employment Standards Act, 2000. |
