Medical Certification - Fmla/cfra (Page 3 of 4) in pdf

Medical Certification - Fmla/cfra Page 3

After review of the signed Employee’s Statement Regarding Seriously Ill Family Member,

does the condition warrant the participation of the employee? (This participation may

include psychological comfort and/or arranging for third-party care for the family member.)

☐

Yes

Estimate the period of time care will be needed or during which the employee’s presence would be

beneficial:

Please answer the following question only if the employee is asking for intermittent leave or a

reduced work schedule:

Is it medically necessary for the employee to be off work on an intermittent basis or to work

less than the employee’s normal work schedule in order to deal with the serious health

condition of the employee or family member?

☐

Yes

If the answer to 7a is yes, please indicate the estimated number of doctor’s visits, and/or

estimated duration of medical treatment, either by the health care practitioner or another

provider of health services, upon referral from the health care provider:

Signature of Health Care Provider

Date

Print Name of Health Care Provider

Address

City

State

Zip

Signature of Employee

Date

Employee’s Statement Regarding Seriously Ill Family Member

To be completed and signed by the employee needing family leave to care for a seriously ill family member. Employee

should provide this section to the health care provider under separate cover. This information is not to be provided to the

employer.

When family care leave is needed to care for a seriously ill family member, the employee must state the care he/she will

provide and an estimate of the time period during which this care will be provided, including a schedule if leave is to be

taken intermittently or on a reduced work schedule:

Signature of Employee

Date

Medical Certification - Fmla/cfra Page 3