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1. The reverse side describes what is meant by a "serious health condition" under both the federal

Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA).

Yes

 No

Does the patient's condition qualify under any of the categories described?

If yes, please check the appropriate category: (1)____

(2)____ (3)____

(4)____

(5)____

(6)____

2. Date medical condition or need for treatment commenced: ___________________________

3. PERIOD OF TIME REQUIRED: Based on the patient’s medical history and your knowledge of the medical condition,

estimate the type of absence and period.

 Off full-time for the period of _____________ to _____________

Comments:____________________________________________________________________________

 Intermittently for the period of_____________ to _____________

Estimate how often (Frequency) and how long each episode of patient incapacity will last (Duration).

(For example: Frequency = 1-2 times per 2 weeks, Duration = 2-3 hours

)

* Frequency:_______ times per _______ week(s); per____ month(s); or “ Other”: ____________________

* Duration: _______ hours or _____ day(s)

Comments:_____________________________________________________________________________

 Work on a reduce work schedule for the period of ____________ to __________

Reduce hours from ________ to ________hours on: M T W TH F Sat Sun

Comments:_____________________________________________________________________________

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such

medical facts may include symptoms or any regimen of continuing treatment.)

________________________________________________________________________________________

5. If employee is able to work intermittent or at a reduce schedule, is employee able to perform their current job duties

Yes

 No

during scheduled work hours? (See attach job duties)

If yes—are there any essential functions the employee is not able to perform? (Answer after reviewing job

description and discussing with employee)

_________________________________________________________________________________________

6. Will the employee need to attend follow-up treatment or appointments because of the employee’s medical

condition? Yes

 No

If yes—Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time

required for each appointment, including any recovery period:

________________________________________________________________________________________

7. 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 ____________________________________Phone Number:_____________

Business address _________________________________________ City/State/Zip________________________

Type of Practice/Medical Specialty _____________________________________Fax Number:________________

Certification Of Health Care Provider For Employee - Family And Medical Leave Act Of 1993 (Fmla)/california Family Rights Act Of 1993 (Cfra) Page 2

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