Certification Of Health Care Provider For Family Member'S Serious Health Condition - Family And Medical Leave Act ("Fmla") & California Family Rights Act ("Cfra")

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CERTIFICATION OF HEALTH CARE PROVIDER
FOR FAMILY MEMBER’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 to care for a family member with a
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 III must be fully completed by the health care provider.
INSTRUCTIONS to EMPLOYEE: Please complete and sign Section II before giving this form to your family member or
his/her health care provider. 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 family member’s 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 the University’s request for this
information, or no later than ____________________.
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:
“ATTENTION: _____________________________________________.”
SECTION I – To be completed by THE UNIVERSITY
Employee's Name
Name of University Representative
University Representative Department Address
Phone
SECTION II – To be completed by EMPLOYEE
INSTRUCTIONS to EMPLOYEE: Please complete and sign Section II before giving this form to your family member or
his/her health care provider. 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 family member’s 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 the University’s request for this
information, or no later than ____________________.
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:
“ATTENTION: _____________________________________________.”
Name of family member for whom you will provide care:
If family member is your child, date of birth:
Relationship of family member to you:
If the child is 18 years of age or older, is the child incapable of self-care because of a mental or physical
No
Yes
disability?
(1) Describe care you will provide to your family member and estimate the duration of leave needed to provide care.
(2) Are you requesting leave on an intermittent or reduced schedule basis?
No
Yes
If yes, please describe the leave schedule you are requesting:
SIGNATURE
EMPLOYEE SIGNATURE
DATE
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