Request For Formal Leave Of Absence Form - California State University Fullerton Page 5


Certification of Health Care Provider for
U.S. Department of Labor
Employee's Serious Health Condition
Wage and Hour Division
(Family and Medical Leave Act)
OMB Control Number: 1235-0003
Expires: 5/31/2018
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require
an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a
medical certification issued by the employee’s health care provider. Please complete Section I before giving this form to
your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to
provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must
generally maintain records and documents relating to medical certifications, recertifications, or medical histories of
employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel
files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance
with 29 C.F.R § 1635.9, if the Generic Information Nondiscrimination Act applies.
Employer name and contact:
California State University, Fullerton - Human Resources (657) 278-2425
Employee's job title:
Regular work schedule:
Employee's essential job functions:
Check if job description is attached:
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical
provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient
medical certification to support a request for FMLA leave due to your own serious health condition. If
requested by your employer, your response is required to obtain or retain the benefit of FMLA protections.
29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result
in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer must give you at least 15 calendar
days to return this form. 29 C.F.R. § 825.305(b).
Your name:
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. 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” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which
the employee is seeking leave. Do not provide information about genetic tests, as defined in 29 C.F.R § 1635.3(f),
generic services, as defined in 29 C.F.R § 1635.3(e), or the manifestation of disease or disorder in the employee's
family members, 29 C.F.R § 1635.3(b). Please be sure to sign the form on the last page.
Provider's name and business address:
Type of practice / Medical specialty:


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