§ 11097. Certification Form.
2 CA ADC § 11097Barclays Official California Code of Regulations
2 CCR § 11097
§ 11097. Certification Form.
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
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:
Yes No
No Is employee able to perform work of any kind? (If “No,” skip next question.)
Yes No
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
No Does (or will) the patient require assistance for basic medical, hygiene, nutritional needs, safety, or transportation?
Yes No
No 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
No 8. Estimate the period of time care is needed or during which the employee's presence would be beneficial:
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
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
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
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
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.
Any period of incapacity due to pregnancy or for prenatal care.
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).
Credits
Note: Authority cited: Section 12935, Government Code. Reference: Section 12945.2, Government Code; California Genetic Information Nondiscrimination Act, Stats. 2011, ch. 261; Family and Medical Leave Act of 1993, 29 U.S.C. § 2601 et seq.; and 29 C.F.R. § 825.
History
1. Change without regulatory effect renumbering former section 7297.10 to new section 11097 and amending section and Note filed 10-3-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 40).
2. Renumbering of former section 11097 to section 11096 and renumbering and amendment of former section 11098 to section 11097, including amendment of section and Note, filed 3-4-2015; operative 7-1-2015 (Register 2015, No. 10).
3. Amendment of section and Note filed 2-27-2019; operative 4-1-2019 (Register 2019, No. 9).
4. Change without regulatory effect amending section filed 12-30-2020 pursuant to section 100, title 1, California Code of Regulations; effective 1-1-2021 (Register 2021, No. 1). (OAL review extended 60 calendar days pursuant to Executive Order N-40-20.)
5. Editorial correction of History 4 (Register 2021, No. 3).
6. Change without regulatory effect amending section filed 1-11-2022 pursuant to section 100, title 1, California Code of Regulations (Register 2022, No. 2).
7. Change without regulatory effect amending section filed 3-20-2023 pursuant to section 100, title 1, California Code of Regulations (Register 2023, No. 12).
This database is current through 4/5/24 Register 2024, No. 14.
Cal. Admin. Code tit. 2, § 11097, 2 CA ADC § 11097
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