Medical Certification for FMLA – Employee

Begin date:_____ End date: _____ If the schedule varies weekly, please indicate the number of hours per day and the number of days per week the employee is able to work:  Yes  No If Yes, please identify the job functions the employee is unable to perform: Is the employee’s health condition permanent or life-long? Yes No

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  Date, Medical, Employee, Number, Certifications, Fmla, Medical certification for fmla employee

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CDCR 7336 Employee Tuberculin Skin Test (TST) and Evaluation

www.cdcr.ca.gov

Check the box if the employee is free of infectious TB, print name, enter license number, sign, and date this section. After evaluation or treatment, provide the original completed and signed CDCR 7336 form to the employee for return to CDCR.

  Date, Name, Employee, Number

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