Family and Medical Leave Act (FMLA) California Family …

(rev 4/2016)CalHR 754 Page 1 of 3 Family and Medical Leave Act (FMLA) California Family Rights Act (CFRA)Certification of Health care Provider for Employee's Serious Health Condition State of CaliforniaPart A: For Completion by the person responsible for administering the Leave program in your department who will be the Department : Complete Section I before giving this form to the employee. Employee Last NameEmployee First NameEmployee Middle NameLast Day Worked:Employee ClassificationEmployee Work UnitDepartment ContactDepartment Contact PhoneAttach a copy of the employee's job description and the essential job functions of the employee's B: For Completion by the EMPLOYEEI nstructions to the Employee: Part A must be completed by the person responsible for administering the Leave program in your department and you must complete Part B before giving this form to your Medical provider.

diabetes, epilepsy, etc.) 3. Any period of incapacity which is long-term due to a condition for which treatment may not be effective (e.g., ... Department of Labor regulations for the Family and Medical Leave Act define a “health care provider” as a 1. doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical ...

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