Family Medical Leave Act - Health Care Provider’s Certification

Dear Health Care Provider: Our employee ______has requested leave under the provisions of Federal and/or California Family and Medical Leave statues. In order for the University to determine whether this leave qualifies for family and medical leave, please complete Section II and return to the employee or CSU East Bay, Human Resources, 25800 Carlos Bee Blvd., Hayward, CA 94542. If you have questions, please contact our office at (510) 885-3634 or Fax (510) 885-2951. Thank you for your assistance.

SECTION I – Employee Information
EMPLOYEE: PLEASE COMPLETE SECTION I, AND TAKE THIS FORM TO YOUR HEALTH CARE PROVIDER
Employee: Dates requested by employee: TO:
Patient (if other than Employee) Relationship to employee:
I confirm that, to the best of my knowledge, all the above information is correct.
Signature:______Home Phone: ______Date: ______
SECTION II - Health Care Provider
EMPLOYEE: If leave is due to EMPLOYEE’S serious health condition
Does this employee have a serious health condition? (See reverse side for definition) Yes No
When did the serious health condition begin?
Is this employee able to perform all or some of the functions of his or her job? Please describe: Yes No
Job description attached Yes No
If intermittent leave or a reduced work schedule is being considered, is it medically necessary? Yes No
If so, please describe the recommended schedule.
Effective date:
Does the employee require other medical accommodations? If yes, please describe: Yes No
Effective date of leave: TO Anticipated return to work date:
DEPENDENT: If leave is due to a serious health condition to care for eligible family member.
Does employee’s family member have a serious health condition? (See reverse side for definition) Yes No
When did the serious health condition begin? Yes No
Does the patient require assistance for basic medical, personal needs, safety or for transportation? (This may include psychological comfort.) Yes No
If intermittent leave or a reduced work schedule is being considered, is it medically necessary? Yes No
If so, please describe the recommended schedule and effective date.
Effective date(s) of leave: TO
Name of Health Care Provider:______Specialty:______
Address______Phone Number: ______
My Signature below verifies that the information provided above is true and accurate.
______
Signature of Health Care Provider Date
ELIGIBLE DEPENDENTS UNDER FAMILY MEDICAL LEAVE
An eligible dependent includes:
·  Spouse
·  Parents
·  Child (biological or adopted)
·  Domestic Partner
NOTE: The definition of eligible or “immediate” family members under Collective Bargaining Units may include a broader interpretation of a qualified dependent. Under the Family and Medical Leave Act only the above-listed dependents are eligible for care under this leave program.
DEFINITION OF A SERIOUS HEALTH CONDITION
A serious health condition is any illness, injury, impairment, physical or mental condition that involves:
v  Any period of incapacity or treatment in connection with or consequent to an overnight stay in a hospital, hospice, or residential medical care facility.
v  Continuing treatment by a health care provider for one or more of the following:
any period of incapacity for more than three consecutive days that also involves treatment two or more times; or
treatment on at least one occasion which results in a regimen of continued treatment under the supervision of a health care provider
v  Any period of incapacity due to pregnancy, for prenatal care.
v  Any period of incapacity due to a chronic serious health condition that:
requires periodic visits for treatment; or
continues over an extended period of time; or
may cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.)
v Any period of incapacity which is long-term that requires continuing supervision, with or without active treatment (e.g., Alzheimer’s, severe strokes, and the terminal stages of diseases).
v  Any period of absence required to receive multiple treatments (including the period of recovery) either for restorative surgery after an accident or other injury, or for a chronic condition such as cancer, or kidney disease. Treatment includes but is not limited to chemotherapy, physical therapy for severe arthritis, and dialysis.
A SERIOUS HEALTH CONDITION IS NOT:
·  Common colds or the flu
·  Ear aches,
·  Minor ulcers or upset stomachs,
·  Routine dental or orthodontia problems,
·  Headaches (but not migraines),
·  Periodontal disease, or
·  Treatments that involve only over-the-counter medicines, bed rest, exercise, drinking fluids, and other activities that can be done without visiting a health care provider.
Department of Labor regulations for the Family and Medical Leave Act define a “health care provider” as: a doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife who is authorized to practice by the State and performing within the scope of their practice as defined by State law.