Looking for a Certification Of Health Care Provider Form Templates? Download it for free!

Certification Of Health Care Provider Form - California Department Of Fair Employment And Housing

T H E D E P A R T M E N T O F F A I R E M P L O Y M E N T A N D H O U S I N G

CERTIFICATION OF HEALTH CARE PROVIDER

For Pregnancy Disability Leave, Transfer and/or Reasonable Accommodation

EMPLOYEE NAME:

Please certify that, because of this patient’s pregnancy, childbirth, or a related medical condition (including, but not

limited to, recovery from pregnancy, childbirth, loss or end of pregnancy, or post-partum depression), this patient needs

(check all appropriate category boxes):

TIME OFF FOR MEDICAL APPOINTMENTS

When:

Duration:

DISABILITY LEAVE

(Because of a patient’s pregnancy, childbirth or a related medical condition, patient cannot perform one or more of

the essential functions of patient’s job or cannot perform any of these functions without undue risk to self, to successful completion of the

pregnancy, or to other persons)

Beginning (Estimate):

Ending (Estimate):

INTERMITTENT LEAVE

Specify the intermittent leave schedule:

Beginning (Estimate):

Ending (Estimate):

REDUCED WORK SCHEDULE

Specify the reduced work schedule:

Beginning (Estimate):

Ending (Estimate):

TRANSFER/BE ASSIGNED TO A LESS STRENUOUS OR HAZARDOUS POSITION OR DUTIES

Specify the medically advisable position/duties:

Beginning (Estimate):

Ending (Estimate):

REASONABLE ACCOMMODATION(S)

Specify (can include, but is not limited to, modifying lifting requirements, providing more frequent breaks, or providing a stool

or chair):

Beginning (Estimate):

Ending (Estimate):

Health Care Provider Name (print):

Medical Health Care Specialty:

License Number:

HEALTH CARE PROVIDER SIGNATURE

DATE

Authority Cited: Government Code sections 12935, subd. (a), and 12945

Reference: Government Code sections 12940, 12945; FMLA, 29 U.S.C. §2601, et seq. and FMLA regulations, 29 C.F.R. § 825

DFEH-E10P-ENG / June 2017

Certification Of Health Care Provider Form - California Department Of Fair Employment And Housing