This government document is issued by Department of Budget and Management for use in Maryland
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https://www.google.com/url?client=internal-element-cse&cx=007821330218074952993:dn8mj_3oupc&q=https://dbm.maryland.gov/employees/Documents/Leave/Form%2520MS%2520402-EE%2520Med%2520Certification.pdf&sa=U&ved=2ahUKEwjrkezfupfxAhXJDOwKHb2hADE4RhAWMAh6BAgEEAE&usg=AOvVaw2EPyiIsrJF8LkZ4cQxydTU