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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

Certification Of Health Care Provider For Employee - Family And Medical Leave Act Of 1993 (Fmla)/california Family Rights Act Of 1993 (Cfra)

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