Request For Certification Under California Fair Employment And Housing Act printable pdf download

Request For Certification Under California Fair Employment And Housing Act

REQUEST FOR CERTIFICATION UNDER CALIFORNIA FAIR EMPLOYMENT AND

HOUSING ACT (FEHA) AND THE AMERICANS WITH DISABILITIES ACT (ADA)

PHYSICIAN/HEALTH CARE PROVIDER: IN ORDER FOR THE EMPLOYER TO BE ABLE TO

PROPERLY EVALUATE THE INFORMATION PROVIDED, PLEASE ANSWER EACH AND

EVERY QUESTION IN DETAIL.

NOTE: 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 individuals’ 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 Name:

Date of Medical Evaluation:

Certification of Qualifying Disability:

A. PHYSICAL DISABILITY: Does the employee have a physiological disease, disorder, condition,

cosmetic impairment or anatomical loss that:

Affects one or more of the body systems: neurological, immunological, musculoskeletal,

special sense organs, respiratory, including speech organs, cardiovascular, reproductive,

digestive, genitourinary, hemic and lymphatic, skin or endocrine?

☐ Yes

☐ No

AND

II.

Does this condition limit a major life activity

☐ Yes

☐ No

B. MENTAL DISABILITY:

Does the employee have any mental or psychological disorder or condition, such as mental

retardation, organic brain syndrome, emotional or mental illness, or specific learning

disability?

☐ Yes

☐ No

AND

II.

Does this disorder or condition limit a major life activity

☐ Yes

☐ No

Limits means that the condition makes the achievement of the life activity difficult. Such activities include

physical, mental and social activities and working. They include functions such as caring for one’s self, performing

manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. Primary attention is to be given

to those life activities that affect employability, or otherwise present a barrier to employment or advancement.

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Request For Certification Under California Fair Employment And Housing Act

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