City of
701 E Carson Street Carson, CA 90745 Telephone (310) 952-1736 Fax (310) 830-2471
Under the Family and Medical Leave Act (FMLA), California Family Rights Act (CFRA),
Pregnancy Disability Leave Law (PDL) and/or applicable City Leave Policies
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Employee’s Name Employee’s Date of Birth Employee’s Identification Number
_________________________________________ ________________________________________ __________________________________________
Employee’s Department Employee’s Job Title Employee’s Regular Work Schedule
A. Nature of the Serious Health Condition (Select One):
1. Inpatient Hospital Care
(An overnight stay in a hospital, hospice or residential care facility, including periods of incapacity associated with
this stay)
2. Incapacity and Treatment
(Treatment two or more times following a period of incapacity of more than three consecutive full calendar days)
3. Pregnancy, Due Date _____/_______/_____ Actual Estimated
(Any period of incapacity due to a pregnancy or recovery from childbirth, including pre- and post-natal care)
4. Chronic Condition
(A period of incapacity or treatment for a condition requiring regular provider visits/treatment, and continuing for
an extended time)
5. Permanent or Long-Term Condition
(A period of incapacity or treatment due to a long-term condition under the continuing supervision of a provider)
6. Multiple Treatments for a Non-Chronic Condition
(A period of absence to receive multiple treatments for restorative surgery or a condition that would result in
incapacity if not treated)
7. None of the Above Explain:
B. Medical Facts about the Serious Health Condition
(such as nature of incapacity, regimen of continuing treatment or follow-up appointments, etc. DO NOT INCLUDE
If chiropractor, is the treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated
by x-ray? Yes No
Is the employee able to perform work of any kind? If “NO”, skip the next question.
No Yes
Is the employee unable to perform any one or more of the essential functions of his/her position? Answer after
reviewing statement from employer of essential functions, or if none provided, after discussing with the employee.
No Yes
City of
701 E Carson Street Carson, CA 90745 Telephone (310) 952-1736 Fax (310) 830-2471
A. Will the employee be incapacitated for a single continuous period of time, including time for treatment and recovery.
No Yes provide start and end dates, below:
____________________________ _______________________________ ____________________________________
Leave Start Date Expected Leave End Date Expected Return to work date
B. Will the employee need intermittent time off due to this serious health condition?
No Yes if Yes, are these absences medically necessary? No Yes, if so provide details below:
Frequency: ____________ hour/days per week/month, or: __________
_______________________ __________________________ Duration: _____________ hours per day, or: ______________
Intermittent Period Intermittent Period Will these absences be consecutive? No Yes
Start Date End Date -If yes, up to ____________days in a row.
*if period end date is not known, please provide an estimated date that re-evaluation will occur.
Estimate the treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment including recovery period:
Dates of Appointments Time Required Per Appointment Recovery Period Required
C. Will the employee need to work part-time or a reduced work schedule due to this serious health condition?
No Yes - if yes, is this schedule medically necessary? No Yes, if so provide details below:
_______________hours per work day, _____________days per workweek
_______________________ __________________________
Reduced Schedule Reduced Schedule
Start Date End Date
IV. Limited Authorization for Release of Health Care Information
_______________________________________________________ ________________________________________
Employee’s Name Employee’s Date of Birth
I authorize the release of any medical information necessary to complete this form. Knowingly providing false information directly, or
through another party, may result in adverse action against the employee.
_________________________________________________________________________ _______________________________________
Employee’s Signature Date
CERTIFICATION BY PROVIDER: By signing below you are certifying that the information you have provided is
accurate and complete, and that this information is based on your personal knowledge of the patient’s condition.
___________________________________________________ ______________________________ _________________________________
Providers Printed Name and Credentials Type of Practice Telephone Number
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Provider’s Office Address (Street, City, State, Zip Code) Best times & Days to Call
__________________________________________________________________________ ___________________________________
Provider’s Signature (No stamps or Proxy Seals Accepted) Date