Medical Certification - Fmla/cfra (Page 2 of 4) in pdf

Medical Certification - Fmla/cfra Page 2

Medical Certification – FMLA/CFRA

Health Care Provider Certification - To be completed by the patient’s health care provider:

Employee Name

Date

Patient’s Name (if other than employee)

Relationship to Employee

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.

Date medical condition or need for treatment commenced:

(Note: The health care provider is not to disclose the underlying diagnosis without the consent

of the patient.)

Probable duration of medical condition or need for treatment:

Attachment A: Definitions describes what is meant by a “serious health condition” under both the

federal Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA).

Does the patient’s condition qualify under any of the categories described?

☐

Yes

If the certification is for the serious health condition of the employee, please answer the following:

Is the employee able to perform work of any kind?

☐

Yes

Is the employee able to perform the essential functions of the employee’s position? (Answer

after reviewing the attached job description provided by the employee that includes the

essential functions of the employee’s position.)

☐

Yes

If yes to either 4a or 4b, please provide proposed or recommended accommodations:

___________________________________________________

If the certification is for the care of the employee’s family member, please answer the following:

The patient does, or will, require assistance for basic medical, hygiene, nutritional needs,

safety or transportation.

☐

Yes

Medical Certification - Fmla/cfra Page 2