Fmla/cfra Med-Cert Certification Of Health (Page 2 of 7) in pdf

Fmla/cfra Med-Cert Certification Of Health Page 2

APPENDIX C

6. a. If medical leave is required for the employee’s absence from work because of the employee’s own

condition (including absences due to pregnancy or a chronic condition, is the employee unable to perform

work of any kind?

b. If able to perform some work, is the employee unable to perform any one or more of the essential

functions of the employee’s job (the employee or the employer should supply you with information about

the essential job functions)?

If yes, please list the essential functions the employee is unable

to perform:

c. If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment?

7. a. If leave is required to care for a family member of the employee with a serious health condition,

does the patient require assistance for basic medical or personal needs or safety, or for

transportation?

b. If no, would the employee’s presence to provide psychological comfort be beneficial to the patient

or assist in the patient’s recovery?

c. If the patient will need care only intermittently or on a part-time basis, please indicate the probable

duraction of this need:

(Signature of Health Care Provider)

(Type of Practice)

(Address)

(Telephone number)

To be completed by the employee needing family leave to care for a family member:

State the care you will provide and an estimate of the period during which care will be provided, including a

schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule:

(Employee Signature)

(Date)

Fmla/cfra Med-Cert Certification Of Health Page 2