Family And Medical Leaves Certification Of Health Care Provider (Employee/family Member)
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COUNTY OF ALAMEDA
FAMILY AND MEDICAL LEAVES
CERTIFICATION OF HEALTH CARE PROVIDER
(Employee/Family Member)
Pursuant to the Family Medical Leave Act (FMLA), California Family Rights Act (CFRA), and/or Pregnancy Disability Act (PDL) the purpose of this form is for
health care providers to: 1) verify an injury or illness of an employee; or 2) verify an injury or illness of an employee’s family member. Under FMLA/CFRA the
definition of a “serious health condition” must be met. This required certification must be returned to your Human Resources Office within 15 days.
For Health Care Provider: In your best estimate, based upon your medical knowledge, experience and examination, please complete Sections I-IV (as
appropriate), sign and date this form. Please limit your responses to the condition for which the employee is seeking leave. 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, do 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.
Employee’s Name: ____________________________________ Employee’s ID#: ______________________________
Family Member’s Name: ________________________________ Relationship to Employee: _____________________
SECTIONS I-IV TO BE COMPLETED BY HEALTH CARE PROVIDER
SECTION I- VERIFICATION OF HEALTH CONDITION
Yes, I am the health care provider and this is a serious health condition, as defined under the FMLA/CFRA, due to the following:
1.
Inpatient hospital care
2.
Absence (incapacitation) of more than three days and continuing treatment
3.
Condition related to pregnancy/childbirth/prenatal care
4.
Chronic serious health condition requiring periodic visits for treatment
5.
Permanent or long-term condition requiring continued supervision of a health care provider
6.
Absences to receive multiple treatments
SECTION II- EMPLOYEE’S HEALTH CONDITION INFORMATION
1. Date condition commenced: ______________
2. Duration of incapacity:
From: ___________ through :___________
3. Is the employee unable to perform any one or more of the essential job functions?
Yes
No
4. If the medical condition is due to pregnancy, childbirth or related medical conditions, provide expected delivery date: ___________
• Due to pregnancy or related medical condition, is it medically advisable to transfer the employee to a less strenuous or
hazardous position or job duties?
Yes
No
5. Is the employee able to perform temporary modified work of any kind?
Yes
No
From: __________
through: __________
• Temporary work restriction(s): ____________________________________________________________________________
6. Is it medically necessary for the employee to work on a temporary reduced work schedule?
Yes
No
• If yes, how many hours can the employee work? ___________ per day, __________ per week;
• From: ______________ through: ________________
7. Is it medically necessary for the employee to attend follow-up treatments/appointments, including recovery time?
Yes
No
• Estimated frequency of intermittent absence for treatments/appointments:
From: ______________ through: ________________
o
Frequency: ______times per ______week(s) _______month(s)
o
Duration:______hours per treatment/appointment
o
8. Is it medically necessary for the employee to be off work on an intermittent basis and/or during episodic flare-ups?
Yes
No
• Estimated frequency of intermittent absences/flare-ups:
From: ______________ through: ________________
o
Frequency: ______times per ______week(s) _______month(s)
o
Duration:______hours or ______day(s) per episode
o
FML Certification of Health Care Provider (FORM 2)
REV. 12/11
Page 1 of 2
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