Documentation Storage

HR Representatives are responsible for determining situations that require medical documentation, a release to return to work, and management of confidential documentation. The below information serves as a guide, however individual department practice and situations may vary.

Requiring Medical Documentation

  • Medical documentation should be required when the information provided by the employee regarding need for leave is insufficient to authorize absence.
     
  • If an employee is eligible for FMLA, the information needed to determine if a qualifying health condition exists can be found on the Health Certification Checklist (pdf).
     
  • For non-FMLA leave requests, the information needed to consider authorized absence is: medical need for absence and duration, intent to return with provision of a defined date, and what is happening during the absence that will allow the employee to return at the end of a leave. A Non-FMLA Leave Request Form may be required, and non-FMLA leaves should be considered first as an accommodation before applicable policy or contracts.
     
  • If an employee is authorized an unpaid leave as an accommodation, the employee must be notified of information required to return to work. FSDS should also be informed of approved leave as an accommodation, as follow up is typically provided to successful return to work

Requiring a Release to Return to Work

  • Medical documentation should be required when a release to work is necessary.
     
  • A release to work should be required for: hospitalizations, continuous absences of two weeks or more, when an employee may be infectious , when an employer has knowledge of limitations/restrictions upon return to work, and/or has safety concerns. HR Representatives should contact Senior Leadership or FSDS for further guidance in requiring a release to work.
     
  • If an employee has been approved for FMLA absence and a release to work is necessary, the employee must be notified of this via the Designation Notice.

Frequently Asked Questions

Medical documentation is any written information a department has regarding an employee’s ability to work that is related to a health condition. Typically the document is provided and signed by the treating health practitioner; however, an employee’s written disclosure also serves as a medical document.

Documentation may be specific to an employee’s personal health condition or an employee’s need for absence for an ill or injured family member. Examples of medical documentation include and are not limited to:

  • Documentation supporting an accommodation request;
  • FMLA health certification forms;
  • Release to work documents;
  • Worker’s Compensation documentation;
  • Any other documentation requesting short term restrictions, work absence, or any other health information; and
  • In rare instances, performance evaluations or disciplinary records erroneously containing reference to health concerns

Whether the information is contained in a document or has been learned by verbal disclosure, The Americans with Disabilities Act and the Family Medical Leave Act considers information of an applicant’s or employee’s medical history, medical condition, leave and accommodation confidential.

First aid and safety personnel should be informed, when appropriate, if the health condition might require emergency treatment; or if any specific procedures are needed in the case of fire or other emergency requiring evacuation.

Medical documentation must be held in a separate medical file (considered a sub file of the personnel file) and is not to be held in the personnel file. References to health conditions in performance evaluations or other employee performance coaching, etc., should be removed from the performance evaluation and placed in the medical file.

Medical documentation is confidential. The HR Representative is responsible to receive (whenever possible) and reviews medical documentation. The HR Representative should forward all medical documentation to FSDS for assistance in complex interactive accommodation processes and when working with FSDS in leave management. The HR Representative will share necessary limitations, absence and accommodation information with manager(s) and supervisor(s). To reduce potential perceived bias or conflict, supervisors should not be informed of diagnoses by other members of management.

Medical documentation should be received by the HR Representative, but if a supervisor does receive it, the supervisor is to forward the medical documentation to the employee’s HR Representative. HR Representatives are to address the information contained in the documentation, i.e., absence needs, limitations, etc., following the leave and interactive process procedures.

Medical documentation is to be stored in a secure and separate file than the personnel file. The file is considered a sub file of the personnel file and access is limited to HR Representatives and employers needing access in the course of assisting the employee in leave, performance and disability matters.

There are two options available when an employee writes health information on the performance evaluation:

  • Remove the entire performance evaluation from the personnel file and transfer it to the medical file. Put a note in the personnel file as a reminder that the evaluation is located in the medical file.
  • Transfer the page that references the health information into the medical file and attach a note to the evaluation that the page is in the medical file.

The medical file will transfer with the employee. However, documentation of accommodations, including leave of absence covered under the ADA, are to be removed from the file and transferred to FSDS. If the employee needs an accommodation in the new job, he/she must make a request to the new department.

Medical documentation of accommodations, including leave of absence, covered under the ADA should be forwarded to FSDS at the time of the employee’s departure. The balance of the medical file is to be maintained by the employer for a period including: current year plus three more years. Following this period, they can be confidentially destroyed.