CERTIFICATION OF HEALTH CARE PROVIDER FOR
EMPLOYEE’S SERIOUS HEALTH CONDITION
Family and Medical Leave Act (FMLA) & California Family Rights Act (CFRA)
PURPOSE of FORM: The below-named employee has requested a leave of absence for his/her health condition which
may qualify as a protected leave under the FMLA and/or CFRA. This medical certification form will provide the University
with information needed to determine if the employee’s requested leave is for a qualifying reason under the FMLA and/or
CFRA. Section II must be fully completed by the health care provider.
INSTRUCTIONS to EMPLOYEE: You are required to submit a timely, complete, and sufficient medical certification to
support your request for FMLA and/or CFRA leave due to your own serious health condition. Providing this completed
form is required to obtain (or retain) the benefit of FMLA and/or CFRA protections for your leave. Failure to provide a
complete and sufficient medical certification to the University may result in a delay or denial of your leave request.
This form should be completed and returned within 15 calendar days of our request for this information. If you
cannot return the completed form within the stated deadline, please contact __________________________________
with the reasons for the delay and the date when the certification will be provided.
You may return the form in person, by mail, or by fax. The fax number is _____________________________.
You should include a fax cover sheet marked “CONFIDENTIAL” and address your fax to:
SECTION I: To be completed by THE UNIVERSITY
EMPLOYEE'S JOB TITLE
EMPLOYEE'S REGULAR WORK SCHEDULE
NAME OF UNIVERSITY REPRESENTATIVE
UNIVERSITY REPRESENTATIVE MAILING ADDRESS
Check if job description listing essential functions is attached
SECTION II – To be completed by HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient (our employee) has requested leave under
the FMLA and/or CFRA. Please answer, fully and completely, all applicable parts. Several questions seek a
response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best
estimate based upon your medical knowledge, experience, and examination of the employee. Be as specific
as you can; terms such as “indefinite,” “unknown,” or “indeterminate” may not be sufficient to determine
FMLA/CFRA coverage. Limit your responses to the condition for which the employee is seeking leave.
Be sure to sign and date the form on page 2.
THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA): The Genetic Information
Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. ‘Genetic information,’ as defined by
GINA, includes an individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received genetic
services, and genetic information of a fetus carried by an individual or an individual’s family member or an
embryo lawfully held by an individual or family member receiving assistive reproductive services.
NOTE: DO NOT DISCLOSE THE EMPLOYEE’S UNDERLYING DIAGNOSIS WITHOUT HIS/HER CONSENT.