Request For Formal Leave Of Absence Form - California State University Fullerton (Page 5 of 18) in pdf

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)

Clear

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:

First

Middle

Last

SECTION III: For Completion by the HEALTH CARE PROVIDER

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:

Telephone:

Fax:

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

Related Articles

Related forms

Related Categories