Yosemite Community College District
Human Resources Operations
Benefits Office
1. Name of Employee: __________________________________________________________________
2. Patient’s Name (if other than employee): _________________________________________________
Date health condition or need for treatment began (Note: The health care provider is not to disclose
the underlying diagnosis without the consent of the patient):
3. Expected duration of condition or need for treatment: ______________________________________
4. The attached sheet describes what is meant by a “serious health condition” (SHC) under both the federal
Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA). Does the
patient’s condition qualify under any of the categories described? If so, please check the appropriate
(1)___ (2)___ (3)___ (4)___ (5)___ (6)___
5. If the certification is for the SHC of the employee, please answer the following:
Is the employee able to perform work of any kind?
(If no, skip next question)
Is the employee unable to perform 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.)
6. If the certification is for the care of the employee’s qualifying person, please answer the following:
Does (or will) the patient require assistance for basic medical, hygiene,
nutritional, safety or transportation needs?
After review of the employee’s signed statement (See Item 9 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
qualifying person.)
7. Estimate the period of time care needed or during which the employee’s presence would be
beneficial: ______________________________________________________________
8. Answer the following question only if the employee is asking for intermittent leave or a reduced
work schedule:
Is it necessary for the employee to be off work on an intermittent
basis or to work less than the employee’s normal work schedule in order to
deal with the serious health condition of the employee or qualifying person?
If the answer to #8 is yes, please indicate the estimated number of visits, and/or estimated duration of the
medical treatment, either by the health care practitioner or another provider of health services, upon
referral from the health care provider.
9. When family care leave is needed to care for a seriously ill family member, the employee shall state
the care that he or she 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:
Please submit a doctor’s note for period of medical leave on physician’s letterhead
10. Health Care Provider Signature: ______________________________________________________
11. Print Name: _______________________________________________________________________
Date: _______________________________Office Phone Number: __________________________
Medical Health Information Release:
12. I authorize the release of any health information necessary to process the above request.
Patient’s Signature: ___________________________________________ Date:________________
13. Print Name: __________________________________________________________________
14. Please return this form to Yosemite Community College District, Office of Human Resources
P.O. Box 4065, Modesto, CA 95352.