921.03 Required Verification SR 14-16, Dated 04/14 (FAM-A)

If the individual requests child care services during a* medical leave from work, require the following verifications:

• A signed and dated statement from the employer, or the individual, if self-employed, stating the individual will be immediately re-employed at the end of the medical leave*; and

• A signed and dated statement from an attending physician, physician’s assistant, advance practice registered nurse or licensed mental health professional describing the reason for the medical leave *and the expected duration. Child care may be authorized for the expected duration or a total of 6 weeks in a calendar year, whichever is less.

*

References: He-C 6910.08(l), RSA 167:83,II(c) and (o), 45 CFR 98.20