One South Van Ness Avenue, 4
th
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
FML2
Family Member
Use This Form For A Family Member’s Serious Health Condition
PLEASE GIVE THIS FORM TO YOUR FAMILY MEMBER’S
HEALTH CARE PROVIDER AFTER COMPLETING SECTION A
CITY AND COUNTY OF SAN FRANCISCO
Certification of Health Care Provider under the
Family and Medical Leave Act (FMLA), California Family Rights Act (CFRA) And
Pregnancy Disability Leave (PDL)
Employee’s Name: _______________________________________Classification: __________________________________
Department: ___________________________________________________________________________________________
Personnel Official’s Name: _________________________________ Telephone Number: ____________________________
Patient/Family Member’s Name: __________________________________ Relationship: ____________________________
Certification of Health Care Provider of a Serious Health Condition
(Family and Medical Leave Act (FMLA) of 1993, California Family Rights Act (CFRA).)
Dear Health Care Provider:
The above-named employee has requested a leave of absence or intermittent leave for the condition of a family
member, which may qualify as a protected leave under the FMLA and/or CFRA. This medical certification form will
provide us with information needed to determine if the employee is eligible for leave under FMLA and/or CFRA.
Sections C-F must be completed by you and returned to the department by the employee or your office. In all cases, it
is the employee’s responsibility to ensure that sufficient medical certification is provided to the employer.
INSTRUCTIONS
The information sought on this form relates only to the family member’s condition for which the employee is taking
leave. For the purposes of this form, “incapacity” is defined as the inability to work, attend school, or perform other
regular daily activities due to the serious health condition itself, treatment of the serious health condition, or recovery
from the condition. “Treatment” includes examinations to determine if a serious health condition exists and evaluations
of the condition. Treatment does not include routine physical examinations, eye examinations, or dental examinations.
A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or
therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not
include taking over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids,
exercise, or other similar activities that can be initiated without a visit to a health care provider.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring
genetic information of an individual or family member of the individual, except as specifically allowed by GINA. To
comply with GINA, we are asking that you not provide any genetic information when responding to this request for
medical information. "Genetic Information," as defined by GINA, includes an individual's family medical history, the
results of an individual's or family member's genetic tests, the fact that an individual or individual's family member
sought or received genetic services, and genetic information of a fetus to be carried by an individual or an individual's
family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Section B: Instructions to the Health Care Provider
Section A: To Be Completed By the Employee
Employee’s Name: ___________________________ Patient’s Name: ___________________________ FML2
Family Member
Page 2 of 4
DHR FML2 (Rev. 08/2017)
The definitions below describe what is meant by a “serious health condition” under the FMLA and/or CFRA. Does the
patient’s condition(s) qualify under any of the categories described? If so, please check the appropriate category.
CATEGORY 1: In-Patient Care
Any period of incapacity or treatment connected with inpatient care (i.e., an overnight stay) 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.
CATEGORY 2: Absence Plus Treatment
A period of incapacity of more than three (3) consecutive full calendar days, and any subsequent treatment or
period of incapacity relating to the same condition, which also involves:
a) Treatment two (2) or more times, within 30 days of the first day of incapacity, by a health care provider, by a
nurse under direct supervision of a health care provider, or by a provider of health care services, e.g., physical
therapist, under orders of, or on referral by, a health care provider; or
b) Treatment by a health care provider on at least one (1) occasion, which results in a regimen of continuing
treatment under the supervision of the health care provider, e.g., prescribed medication.
CATEGORY 3: Pregnancy or Prenatal Care
Any period of incapacity due to pregnancy, or for prenatal care. Expected delivery date: _____________________
CATEGORY 4: Chronic Conditions
Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. A chronic
serious health condition is one which:
a) Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under
direct supervision of a health care provider;
b) Continues over an extended period of time, including recurring episodes of a single underlying condition; and
c) May cause episodic rather than a continuing period of incapacity, e.g., asthma, diabetes, epilepsy, etc.
CATEGORY 5: Permanent or 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 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.
CATEGORY 6: Conditions Requiring Multiple Treatments
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, for:
a) Restorative surgery after an accident or other injury; or
b) A condition that would likely result in a period of incapacity of more than three (3) consecutive, full calendar
days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe
arthritis (physical therapy), or kidney disease (dialysis).
NO CATEGORY APPLIES
Continue To Next Page
Section C: Definition of a Serious Health Condition
Employee’s Name: ___________________________ Patient’s Name: ___________________________ FML2
Family Member
Page 3 of 4
DHR FML2 (Rev. 08/2017)
Note: The health care provider is not to disclose the underlying diagnosis without the patient’s consent.
1. State the approximate date the condition began: ______________________________________________________
2. State the probable duration of the condition or need for treatment: ________________________________________
3. State the probable duration of the patient’s incapacity, if different from the duration of the condition:
_______________________________________________________________________________________________
____
Section D: Supporting Medical Facts
4. After review of the employee’s signed statement (see attached Request for Leave form), 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
5. Does (or will) the patient require assistance from the employee with basic medical, hygiene, nutritional, safety,
transportation needs or the participation of physical or psychological care? Yes No
CONTINUOUS LEAVE
The patient will be incapacitated for a continuous period of time and will require the employee to be on CONTINUOUS
LEAVE for the patient’s treatment and/or recovery.
Estimate the beginning and ending dates for the period of incapacity: From ____________ through __________
INTERMITTENT LEAVE
It is medically necessary for the employee to take INTERMITTENT LEAVE because the family member’s serious health
condition causes episodic incapacity due to flare-ups or urgent care.
a. Estimate the frequency of flare-ups or the need for urgent care:
Frequency: __________ times per __________ week / month / year (circle one)
b. Estimate the duration of time the employee is required to care for the family member on each occasion:
Duration: ________hours / days per incident (circle one)
Dates flare-ups or need for urgent care may occur: From ___________________ through _________________
TREATMENT OR APPOINTMENTS
It is medically necessary for the employee to attend or transport the family member to follow- up TREATMENT or
APPOINTMENTS because of the family member’s serious health condition.
Scheduled Treatment/Appointments: ________times per ________ week / month / year (circle one)
Estimate dates, times and length of scheduled appointments: __________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Continue To Next Page
Employee’s Name: ___________________________ Patient’s Name: ___________________________ FML2
Family Member
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DHR FML2 (Rev. 08/2017)
____________________________________________ ___________________________________________
(Signature of Health Care Provider) (Date)
____________________________________________ ___________________________________________
(Print Name of Health Care Provider) (License No.)
____________________________________________ _____________________________________________
(Address) (Phone No.)
Thank you for your assistance.
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PART-TIME SCHEDULE
It is medically necessary for the employee to work a PART-TIME SCHEDULE due to the family member’s serious health
condition.
Indicate the part-time schedule the employee needs:
Employee can work _____ hours per day for_____ days per week from _______________ through ______________
Additional Comments:_______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Department of Labor regulations for the Family and Medical Leave Act define a “health care provider” as a
a. doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse
practitioner, nurse-midwife, or clinical social worker, physician’s assistant, who is authorized to practice by the
State and performing within the scope of their practice as defined by State law, or a Christian Science practitioner.
b. any provider the employee's group health plan will accept certification of a serious health condition to
substantiate a claim for benefits.
Section F: Definition of Health Care Provider