Request For Formal Leave Of Absence Form - California State University Fullerton Page 4


Reasonable accommodation(s). [Specify medically advisable needed accommodation(s).
These could include, but are not limited to, modifying lifting requirements, or providing
more frequent breaks, or providing a stool or chair.]
Beginning (Estimate):
Ending (Estimate):
Name, license number and medical/health care specialty [printed] of health care provi
Signature of health care provider:
Authority Cited: Government Code sections 12935, subd. (a), and 12945.
Reference: Government Code sections 12940, 12945; FMLA, 29 U.S.C. §2601, et seq. and
FMLA regulations, 29 C.F.R. § 825.


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