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LOS ANGELES UNIFIED SCHOOL DISTRICT

Family and Medical Leave Act

Certification by Health Care Provider of

Employee’s Serious Health Condition

SECTION I: For Completion by the SUPERVISOR

INSTRUCTIONS to the SUPERVISOR: The Family and Medical Leave Act (FMLA) provides that an employer may require an

employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification

issued by the employee’s health care provider. Please complete Section I before giving this form to your employee. You may not ask

the employee to provide more information than allowed under FMLA regulations. Employers must generally maintain records and

documents relating to medical certifications, recertifications, or medical histories of employees created for FMLA purposes as

confidential medical records in separate files/records from the usual personnel files.

DATE:

TO:

Employee & Employee #

FROM:

School Site/Division:

Supervisor or Administrator

Employee’s job title:

Regular work scheduled:

Employee’s essential job functions:

Check if job description is attached: _____

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. FMLA permits

an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave

due to your own serious health condition. If requested by your supervisor, your response is required to obtain or retain the benefit of

FMLA protections. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request.

Your supervisor must give you at least 15 calendar days to return this form.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II

from requiring genetic information of an individual or family member of an individual, except as specifically allowed by this law. To

comply with GINA, do not provide any genetic information when responding to this request for medical information. “Genetic

information”, as described by GINA, includes an individual or individual’s family member’s medical history, results of an individual

or individual’s family member’s genetic tests, the fact that an individual or individual’s family member sought or received genetic

services, and genetic information of a fetus carried to an individual or individual’s family member or an embryo lawfully held by an

individual or individual’s family member receiving assistive reproductive services.

Your name:

First

Middle

Last

Starting date of absence:_______________________; Last date of absence (expected): ______________________________

_______________________________________ __________ _______________________________________ _________

Employee’s Signature

Date

Signature-Family Member (or Guardian), if applicable

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under FMLA. Please answer, fully and

completely, all applicable parts below. Several questions seek a response as to the frequency or duration of a condition, treatment, etc.

Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as

specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage.

Limit your responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page.

Provider’s name and business address:

Page 1 of 3

07/2012

Certification By Health Care Provider Of Employee'S Serious Health Condition Form - Los Angeles Unified School District

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