CERTIFICATION OF HEALTH CARE PROVIDER
for California Family Rights Act (CFRA) or Family and Medical Leave Act (FMLA)
IMPORTANT NOTE: The California Genec Informaon Nondiscriminaon Act of 2011 (CalGINA) prohibits employers
and other covered enes from requesng, or requiring, genec informaon of an individual or family member of
the individual except as specically allowed by law. To comply with CalGINA, we are asking that you not provide any
genec informaon when responding to this request for medical informaon. “Genec Informaon,” as dened by
CalGINA, includes informaon about the individual’s or the individual’s family member’s genec tests, informaon
regarding the manifestaon of a disease or disorder in a family member of the individual, and includes informaon
from genec services or parcipaon in clinical research that includes genec services by an individual or any family
member of the individual. “Genec Informaon” does not include informaon about an individual’s sex or age.
1. Employee Name:
2. Paent’s Name (if other than employee):
Is paent the employee’s family member (i.e., child, parent, parent-in-law, grandparent, grandchild, sibling, spouse,
domesc partner, or designated person)?
Note: “child” includes a biological, adopted, foster child, a stepchild, a legal ward, a child of the employee’s domesc
partner, and a person to whom the employee stands in loco parens. “Parent” includes a biological, foster, or adopve
parent, a parent-in-law, a stepparent, a legal guardian, or other person who stood in loco parens to the employee when
the employee was a child. A biological or legal relaonship is not necessary for a person to have stood in loco parens
to the employee as a child. “Designated person” means any individual related by blood or whose associaon with the
employee is the equivalent of a family relaonship.
Yes No
3. Date medical condion or need for treatment commenced [NOTE: THE HEALTH CARE PROVIDER IS NOT TO DISCLOSE
THE UNDERLYING DIAGNOSIS WITHOUT CONSENT OF THE PATIENT]:
4. Probable duraon of medical condion or need for treatment:
5. Below is a descripon of what cons
tutes a “serious health condion” under both the
federal Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA).
Does the paent’s condion qualify as a serious health condion?
Yes
No
6. If the cercaon is for the serious health condion of the employee, please answer the follo
wing:
Is the employee able to perform work of any kind? (If “No,” skip next queson) Yes No
Is employee unable to perform any one or more of the essenal funcons of employ
ee’s
posion? (Answer aer reviewing statement from employer of essenal funcons of
employee’s posion, or, if none provided, aer discussing with employee.)
Yes
No
7. If the cercaon is for the care of the employee’s family member, please answer the following:
Does (or will) the paent require assistance for basic medical, hygiene,
nutrional needs, safety, or transportaon?
Yes No
Aer review of the employee’s signed statement (see item 10 below), does the
condion warrant the parcipaon of the employee? (This parcipaon may include
psychological comfort and/or arranging for third-party care for the family member.)
Yes No
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8. Esmate the period of me care is needed or during which the employee’s presence would be benecial:
9. Please answer the following quesons only if the employee is asking for intermient leave or a reduced work schedule:
Intermient Leave: Is it medically necessary for the employee to be
o work on an intermient basis due to the serious health condion
of the employee or family member?
Yes No
If yes, please indicate the esmated frequency of the employee’s need for intermient leave due to the serious
health condion, and the duraon of such leaves (e.g. 1 episode every 3 months lasng 1-2 days):
Frequency: ____ mes per ____week(s) ____month(s) Duraon: ____hours or ____day(s) per episode
Reduced Schedule Leave: Is it medically necessary for the employee
to work less than the employee’s normal work schedule due to the
serious health condion of the employee or family member?
Yes No
If y
es, please indicate the part-me or reduced work schedule the employee needs:
Frequency: ____hour(s) per day; ____days per week, from _________________ through ____________________.
Time O for Medical Appointments or Treatment: Is it medically
necessary for the employee to take me o work for doctor’s visits
or medical treatment, either by the health care praconer or
another provider of health services?
Yes No
If yes, please indicate the esmated frequency of the employee’s need for leave for doctor’s visits or medical
treatment, and the me required for each appointment, including any recovery period:
Frequency: ____ mes per ____ week(s) ____ month(s) Duraon: ____ hours or ____ day(s) per apt./treatment
ITEM 10 IS TO BE COMPLETED BY THE EMPLOYEE NEEDING FAMILY LEAVE.
****TO BE PROVIDED TO THE HEALTH CARE PROVIDER UNDER SEPARATE COVER.
10.
When family care leave is needed to care for a seriously-ill family member, the employee shall state the care the
employee will provide and an esmate of the me period during which this care will be provided, including a
schedule if leave is to be taken intermiently or on a reduced work schedule:
Printed Name of Health Care Provider:
SIGNATURE OF HEALTH CARE PROVIDER DATE
SIGNATURE OF EMPLOYEE DATE
SERIOUS HEALTH CONDITION
“Serious health condion” means an illness, injury (including, but not limited to, on-the-job injuries), impairment, or
physical or mental condion of the employee or a child, parent, parent-in-law, grandparent, grandchild, sibling, spouse,
domesc partner, or designated person of the employee that involves either inpaent care or connuing treatment,
including, but not limited to, treatment for substance abuse. A serious health condion may involve one or more of the
following:
HOSPITAL CARE
Inpaent care in a hospital, hospice, or residenal medical care facility, including any period of incapacity or subsequent
treatment in connecon with or consequent to such inpaent care. A person is considered an “inpaent” when a heath
care facility formally admits the person to the facility with the expectaon that the person will remain at least overnight
and occupy a bed, even if it later develops that such person can be discharged or transferred to another facility and does
not actually remain overnight.
ABSENCE PLUS TREATMENT
(a) A period of incapacity of more than three consecuve calendar days (including any subsequent treatment or period
of incapacity relang to the same condion), that also involves:
1. Treatment two or more mes by a health care provider, by a nurse or physician’s assistant under direct supervision of
a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral
by, a health care provider; or
2. Treatment by a health care provider on at least one occasion which results in a regimen of connuing treatment under
the supervision of the health care provider.
PREGNANCY
[NOTE: An employee’s own incapacity due to pregnancy is covered as a serious health condion under FMLA but not
under CFRA]
Any period of incapacity due to pregnancy or for prenatal care.
CHRONIC CONDITIONS REQUIRING TREATMENT
A chronic condion, which:
1. Requires periodic visits for treatment by a health care provider, or by a nurse of physician’s assistant under direct
supervision of a health care provider;
2. Connues over an extended period of me (including recurring episodes of a single underlying condion); and
3. May cause episodic rather than a connuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
PERMANENT/LONG-TERM CONDITIONS REQUIRING SUPERVISION
A period of incapacity which is permanent or long-term due to a condion for which treatment may not be eecve. The
employee or family member must be under the connuing supervision of, but need not be receiving acve treatment by,
a health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages of a disease.
MULTIPLE TREATMENTS (NON-CHRONIC CONDITIONS)
Any period of absence to receive mulple treatments (including any period of recovery therefrom) by a health care
provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for
restorave surgery aer an accident or other injury, or for a condion that would likely result in a period of incapacity
of more than three consecuve calendar days in the absence of medical intervenon or treatment, such as cancer
(chemotherapy, radiaon, etc.), severe arthris (physical therapy), or kidney disease (dialysis).
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