Medical Certificate for Family Caregiver Leave

LifeWorks has been contracted by the caregiver’s employer to administer job protected leave in accordance with provincial
regulations. Employees are entitled under provincial legislation to take time away from work to care for an ill family member.
As the medical provider for the patient, you are asked to certify that the patient’s current state of health meets the criteria set
forth by provincial legislation and that the patient requires care and support from the caregiver.

Definition of “care” and “support”

Care means all care that the patient needs because of their state of health other than care received from health care
professionals. Support means all psychological and emotional support the patient needs because of their state of health.

Definition of ‘critically ill”

Critically Ill refers to someone whose baseline health has changed significantly and whose life is at risk as a result of illness or
injury.

Guidance for medical doctors and nurse practitioners for completing the form
If the patient is at significant risk of death within 26 weeks, healthcare provider should complete Part A to certify that the
employee meets the criteria for Compassionate Care Leave. If the patient is not at significant risk of death within 26 weeks,
but meets the definition of ‘critically ill’, complete Part B.

Ospina Sebastian
2023-12-27
Caregiver’s Last Name Caregiver’s First Name Certificate Due Date (yyyy-mm-dd)

Sanchez Maria Teresa 1946-10-27

Patient’s Last Name Patient’s First Name Patient’s Date of Birth

Part A. Compassionate Care

The patient was last examined on 2023-10-20 and I certify that:

(yyyy-mm-dd)

Yes No

1. The patient has a serious medical condition and a significant risk of death within the next 6 months. ☐ X☐

2. The patient requires the care and/or support of one or more family members over the next 6 months. X☐ ☐
Part B. Critical Illness -This must be thoroughly completed.

Based on my assessment, I certify that the three (3) conditions listed below existed as of 2023-12-20
(yyyy-mm-dd)

Yes No

1. The patient’s life is at risk as a result of illness or injury X☐ ☐

2. There has been a significant change in baseline health of this patient X☐ ☐

3. The patient requires care or support from one or more family members X☐ ☐

In my professional opinion, the patient requires care from2023-12-20 through 2024-02-20

(yyyy-mm-dd) (yyyy-mm-dd)

I am a doctor ☐
X I am a nurse practitioner ☐

2023-12-2
Signature (Medical Doctor or Nurse Practitioner Date (yyyy-mm-dd)

Medical Provider Contact Information

Name License/Registration Number

Henry Hernán Bolaños Bravo 12980199
Address City or Town
Calle 33# 36-50 Villavicencio
Province, territory, or state Country Postal or zip code Phone number
Meta Colombia 500221 +57 311-680-8319

Medical doctors and nurse practitioners outside Canada must also provide the following information:

University where certificate obtained Year certificate obtained Country of Practice

Universidad del Cauca 2022 Colombia
Hospital or clinic affiliation License or Registration Number
Clínica Meta 12980199

The information provided on this form is collected by LifeWorks, a third-party leave administrator of the employer, and is used to
determine eligibility and entitlement for a leave of absence under provincial leave legislation. The personal information collected is
administered in accordance with the Department of Employment and Social Development Act and the Privacy Act. Individuals have
the right to the protection of and access to their personal information.