CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE
Family and Medical Leave Act of 1993 (FMLA)/California Family Rights Act of 1993 (CFRA)
Please complete this confidential form and return it to: Human Resources
5150 N Maple Ave M/S JA71 Fresno, CA 93740-8026 Phone: 559 278-2032 Fax: 559 278-4275
Employee (Patient) Name: ___________________________________
HR Contact________________________
(PRINT NAME)
(NAME)
Employee’s Job title: _______________________________________Regular work schedule:___________________
(WORKDAY/TIME)
Yes
No
Job description of employee’s essential job functions is attached:
Employee Signature: __________________________________________________ Date: ________________
For Completion by the Health Care Provider
Instructions to the Health Care Provider: Your patient has requested leave under the FMLA/CFRA. Answer, fully and
completely all applicable parts. 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” are
not sufficient to determine FMLA/CFRA coverage. Limit your responses to the condition for which the employee is
seeking leave.
Note: the health care provider is not to disclose the underlying diagnosis without the consent of the patient. In addition, 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.
DEFINITION OF SERIOUS HEALTH CONDITION
A “Serious Health Condition” means an illness, injury, impairment, or physical or mental condition that involves one of the following:
1. Hospital Care : Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any
period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.
2. Absence Plus Treatment
(a) A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of
incapacity relating to the same condition), that also involves:
(1) Treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a
health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a
health care provider; or
(2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the
supervision of the health care provider.
3. Pregnancy [NOTE: An employee’s own incapacity due to pregnancy is covered as a serious health condition under FMLA but
not under CFRA.] Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Conditions Requiring Treatment : A chronic condition which:
(1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under direct
supervision of a health care provider;
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
5. Permanent/Long-term Conditions Requiring Supervision
A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee
or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care
provider. Examples include Alzheimer's, a severe stroke, or the terminal stages of a disease.
6. Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery there from) by a health care provider or by
a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an
accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar
days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.) severe arthritis (physical
therapy), kidney disease (dialysis).
(Complete Reverse Side)
Rev:
09/11