Request For Formal Leave Of Absence Form - California State University Fullerton (Page 9 of 18) in pdf

Certification of Health Care Provider for

U.S. Department of Labor

Family Member’s Serious Health Condition

Wage and Hour Division

(Family and Medical Leave Act)

Clear

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

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 to care for a covered family member with a serious health

condition to submit a medical certification issued by the health care provider of the covered family member. 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’ family members, 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

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family member or

his/her 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 to care for a covered family member with a 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 to your employer. 29 C.F.R. § 825.305.

Your name:

First

Middle

Last

Name of family member for whom you will provide care:

First

Middle

Last

Relationship of family member to you:

If family member is your son or daughter, date of birth:

Describe care you will provide to your family member and estimate leave needed to provide care:

Employee Signature

Date

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Request For Formal Leave Of Absence Form - California State University Fullerton Page 9