Certification Of Health Care Provider For Employee'S Pregnancy Disability - California Pregnancy Disability Leave Law (Pdll)
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CERTIFICATION OF HEALTH CARE PROVIDER
FOR EMPLOYEE’S PREGNANCY DISABILITY
California Pregnancy Disability Leave Law (PDLL)
P
URPOSE of FORM: The below-named employee has requested a leave of absence due to a disability resulting from her
pregnancy, childbirth, or related medical condition which may qualify as a protected leave under PDLL. This medical
certification form will provide the University with information needed to determine if the employee’s requested leave is for
a qualifying reason under PDLL. Section II must be fully completed by the health care provider.
INSTRUCTIONS to EMPLOYEE: You are required to submit a timely, complete, and sufficient medical certification to
support your request for pregnancy disability leave due to your pregnancy, childbirth, or related medical condition.
Providing this completed form is required to obtain (or retain) the benefit of PDLL protections for your leave. Failure to
provide a complete and sufficient medical certification to the University may result in a delay or denial of your leave
request.
This form should be completed and returned within 15 calendar days. If you cannot return the completed form within
gmebenefits@ucsd.edu
the stated deadline, please contact __________________________________ with the reasons for the delay and the date
when the certification will be provided.
(619) 543-2990
You may return the form in person, by mail, or by fax. The fax number is ______________________.
You should include a fax cover sheet marked “CONFIDENTIAL” and address your fax to:
GME - Benefits Coordinator
“ATTENTION: _____________________________________________.”
SECTION I – To be completed by THE UNIVERSITY
EMPLOYEE'S NAME
EMPLOYEE'S JOB TITLE
Resident
EMPLOYEE'S REGULAR WORK SCHEDULE
Varies
NAME OF UNIVERSITY REPRESENTATIVE
UNIVERSITY REPRESENTATIVE MAILING ADDRESS
200 W. Arbor Drive, San Diego, CA 92103-8829
TELEPHONE
FAX
E-MAIL
(619) 543-7820
(619) 543-2990
gmebenefits@ucsd.edu
Check if job description listing essential functions is attached
SECTION II – To be completed by HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient (our employee) has requested leave under the PDLL
due to a disability resulting from her pregnancy, childbirth, or related medical condition. Please answer, fully and
completely, all applicable parts. Your answers should be based upon your medical knowledge, experience, and
examination of the employee. Be sure to sign and date the form on page 2.
THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA): 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.
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