California Code of Regulations › Title 2 - Administration › Division 4.1 - Civil Rights Department › Chapter 5 - Civil Rights Council › Subchapter 2 - Discrimination in Employment › Article 11 - California Family Rights Act › Section 11097 - Certification Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For leaves involving serious health conditions under CFRA
						or FMLA, the employer may utilize the following Certification of Health Care
						Provider form or its equivalent. Employers may also utilize any other
						certification form so long as the health care provider does not disclose the
						underlying diagnosis of the serious health condition involved without the
						consent of the patient.
CIVIL RIGHTS COUNCIL
CERTIFICATION OF HEALTH CARE PROVIDER
(California Family Rights Act (CFRA) or Family and
						Medical Leave Act (FMLA))
IMPORTANT NOTE: The California Genetic Information
						Nondiscrimination Act of 2011 (CalGINA) prohibits employers and other covered
						entities from requesting, or requiring, genetic information of an individual or
						family member of the individual except as specifically allowed by law. To
						comply with the Act, we are asking that you not provide any genetic information
						when responding to this request for medical information. "Genetic Information,"
						as defined by CalGINA, includes information about the individual's or the
						individual's family member's genetic tests, information regarding the
						manifestation of a disease or disorder in a family member of the individual,
						and includes information from genetic services or participation in clinical
						research that includes genetic services by an individual or any family member
						of the individual. "Genetic Information" does not include information about an
						individual's sex or age.
1. Employee's
					 Name: ___________________________
2. Patient's Name (If other than employee):
					 ___________________________
Is patient the employee's family member (i.e., child,
						parent, grandparent, grandchild, sibling, spouse, domestic partner, or
						designated person)?
(Note: "child" includes a biological, adopted, foster
						child, a stepchild, a legal ward, a child of the employee's domestic partner,
						and a person to whom the employee stands in loco parentis. "Parent" includes a
						biological, foster, or adoptive parent, a parent-in-law, a stepparent, a legal
						guardian, or other person who stood in loco parentis to the employee when the
						employee was a child. A biological or legal relationship is not necessary for a
						person to have stood in loco parentis to the employee as a child. "Designated
						person" means any individual related by blood or whose association with the
						employee is the equivalent of a family relationship.)
Yes [] No []
3. Date medical condition or need for
					 treatment commenced [NOTE: THE HEALTH CARE PROVIDER IS NOT TO DISCLOSE THE
					 UNDERLYING DIAGNOSIS WITHOUT THE CONSENT OF THE PATIENT]:
					 ___________________________
4.
					 Probable duration of medical condition or need for treatment:
					 ___________________________
5.
					 Below is a description of what constitutes a "serious health condition" under
					 both the federal Family and Medical Leave Act (FMLA) and the California Family
					 Rights Act (CFRA). Does the patient's condition qualify as a serious health
					 condition?
Yes [] No []
6. If the certification is for the serious
					 health condition of the employee, please answer the following:
Is employee able to perform work of any kind? (If "No,"
						skip next question.)
Yes [] No []
Is employee unable to perform any one or more of the
						essential functions of employee's position? (Answer after reviewing statement
						from employer of essential functions of employee's position, or, if none
						provided, after discussing with employee.)
Yes [] No []
7. If the certification is for the care of
					 the employee's family member, please answer the following:
Does (or will) the patient require assistance for basic
						medical, hygiene, nutritional needs, safety, or transportation?
Yes []
After review of the employee's signed statement (See Item
						10 below), does the condition warrant the participation of the employee? (This
						participation may include psychological comfort and/or arranging for
						third-party care for the family member.)
Yes [] No []
8. Estimate the period of time care is needed
					 or during which the employee's presence would be beneficial:
					 ___________________________
9.
					 Please answer the following questions only if the employee is asking for
					 intermittent leave or a reduced work schedule.
Intermittent Leave: Is it medically necessary for the
						employee to be off work on an intermittent basis due to the serious health
						condition of the employee or family member?
Yes [] No []
If yes, please indicate the estimated frequency of the
						employee's need for intermittent leave due to the serious health condition, and
						the duration of such leaves (e.g. 1 episode every 3 months lasting 1-2
						days):
Frequency: _____ times per _____ week(s) _____ month(s)
						Duration: _____ hours or _____ day(s) per episode
Yes [] No []
Reduced Schedule Leave: Is it medically necessary for the
						employee to work less than the employee's normal work schedule due to the
						serious health condition of the employee or family member?
If yes, please indicate the part-time or reduced work
						schedule the employee needs: _____ hour(s) per day; _____ days per week, from
						__________ through _______________
Yes [] No []
Time Off for Medical Appointments or Treatment: Is it
						medically necessary for the employee to take time off work for doctor's visits
						or medical treatment, either by the health care practitioner or another
						provider of health services?
If yes, please indicate the estimated frequency of the
						employee's need for leave for doctor's visits or medical treatment, and the
						time required for each appointment, including any recovery period: Frequency:
						_____ times per _____ week(s) _____ month(s) Duration: _____ hours or _____
						day(s) per appointment/treatment
Yes [] No []
ITEM 10 IS TO BE COMPLETED BY THE EMPLOYEE NEEDING FAMILY
						LEAVE. ****TO BE PROVIDED TO THE HEALTH CARE PROVIDER UNDER SEPARATE
						COVER.
10. When family care
					 leave is needed to care for a seriously-ill family member, the employee shall
					 state the care the employee will provide and an estimate of the time period
					 during which this care will be provided, including a schedule if leave is to be
					 taken intermittently or on a reduced work schedule:
___________________________
___________________________
___________________________
___________________________
11. Printed name of health care provider:
___________________________
Signature of health care provider:
Date: _________________________
___________________________
12. Signature of Employee:
Date: _________________________
-- Serious Health Condition --
"Serious health condition" means an illness, injury
						(including, but not limited to, on-the-job injuries), impairment, or physical
						or mental condition of the employee or a child, parent, parent-in-law,
						grandparent, grandchild, sibling, spouse, domestic partner, or designated
						person of the employee that involves either inpatient care or continuing
						treatment, including, but not limited to, treatment for substance abuse. A
						serious health condition may involve one or more of the following:
1. Hospital Care Inpatient care in a
					 hospital, hospice, or residential medical care facility, including any period
					 of incapacity or subsequent treatment in connection with or consequent to such
					 inpatient care. A person is considered an "inpatient" when a heath care
					 facility formally admits the person to the facility with the expectation that
					 the person will remain at least overnight and occupy a bed, even if it later
					 develops that such person can be discharged or transferred to another facility
					 and does not actually remain overnight.
2. Absence Plus Treatment
(a) A period of incapacity of more than three
					 consecutive calendar days (including any subsequent treatment or period of
					 incapacity relating to the same condition), that also involves:
(1) Treatment two or more times by a health
					 care provider, by a nurse or physician's assistant under direct supervision of
					 a health care provider, or by a provider of health care services (e.g.,
					 physical therapist) under orders of, or on referral by, a health care provider;
					 or
(2) Treatment by a health care
					 provider on at least one occasion which results in a regimen of continuing
					 treatment under the supervision of the health care
					 provider.
3.
					 Pregnancy [NOTE: An employee's own incapacity due to pregnancy is covered as a
					 serious health condition under FMLA but not under CFRA]
Any period of incapacity due to pregnancy or for prenatal
						care.
4. Chronic Conditions
					 Requiring Treatment - A chronic condition which:
(1) Requires periodic visits for treatment by
					 a health care provider, or by a nurse or physician's assistant under direct
					 supervision of a health care provider;
(2) Continues over an extended period of time
					 (including recurring episodes of a single underlying condition); and
(3) May cause episodic rather than a
					 continuing period of incapacity (e.g., asthma, diabetes, epilepsy,
					 etc.).
5.
					 Permanent/Long-term Conditions Requiring Supervision - A period of incapacity
					 which is permanent or long-term due to a condition for which treatment may not
					 be effective. The employee or family member must be under the continuing
					 supervision of, but need not be receiving active treatment by, a health care
					 provider. Examples include Alzheimer's, a severe stroke, or the terminal stages
					 of a disease.
6. Multiple
					 Treatments (Non-Chronic Conditions) - Any period of absence to receive multiple
					 treatments (including any period of recovery therefrom) by a health care
					 provider or by a provider of health care services under orders of, or on
					 referral by, a health care provider, either for restorative surgery after an
					 accident or other injury, or for a condition that would likely result in a
					 period of incapacity of more than three consecutive calendar days in the
					 absence of medical intervention or treatment, such as cancer (chemotherapy,
					 radiation, etc.), severe arthritis (physical therapy), or kidney disease
					 (dialysis).