Medical Certification - Fmla/cfra printable pdf download

Medical Certification - Fmla/cfra

Medical Certification - FMLA/CFRA ~ Instructions

Use this form to obtain physician or medical practitioner certification that the employee or a family member is

disabled due to a “serious health condition,” as defined in Attachment A: Definitions.

Due to the confidential nature of this information, use this form as follows:

Provide the employee with a copy of his/her job description along with this form. Make sure the job

description identifies the essential functions of the employee’s position.

Instruct the employee to:

Give the job description and Health Care Provider Certification section of the form to the

health care provider.

Complete and sign the Employee’s Statement Regarding Seriously Ill Family Member

section, if the employee is requesting family leave to care for a seriously ill family member,

and provide this section under separate cover to the health care provider.

Have the health care provider complete and sign the Health Care Provider Certification

section.

Sign and return only the Health Care Provider Certification section to you for

documentation purposes, after it is completed by the health care provider.

File the completed Health Care Provider Certification section in the employee’s confidential medical

file.

Medical Certification - Fmla/cfra