Instructions:
 Complete “Employee Information” section of the application and submit to Human Resources, Administration

Building (01), Room 110, Attention: Terizza Miller
Deliver the Certification of Health Care Provider Form to the treating physician who will then complete the form and return it directly to Human Resources. Reference the provided job description with discussing potential work restrictions or evaluating your ability to perform your customary job responsibilities.
Employee Name:
Department:
Current Mailing Address:
Employee ID Number (not SSN):
Campus Extension:
Telephone Number:
Dates for which employee is requesting leave:
Effective:______________________________
Through:_______________________________
Reason for Leave (see CSU FML Flyer for eligibility and definitions) :
To care for newborn
To care for newly adopted child or newly placed foster child
To care for child, spouse, domestic partner, or parent
Employee’s serious health condition
Pregnancy Disability
Qualifying Military Exigency Leave
Service Member Care Leave
Employee Signature:
Eligibility:
All full-time and part-time employees employed for at least one academic year or 12 months (not necessarily continuously) preceding the request for FML are eligible.
Student employees employed at least one year (not necessarily continuously) and who worked at least 1,250 hours in the 12 months preceding the leave are eligible.
Is employee eligible for FML?
Yes No
The following has been provided to the employee:
U.S. Dept of Labor Employee Rights and Responsibilities
Cal Poly Family and Medical Leave (FML) Policy flyer
Designation Notice determining eligibility
Disability Programs Analyst:
Date:
Has employee used FML leave within the past 12 months?
Yes No
If Yes, remaining weeks of entitlement for FML:
Date information was provided to the employee:
Method of Presentation within 5 business days:
In person
US Mail
Campus email
Date:
For questions or concerns, please contact
Terizza Miller, Disability Programs Analyst  (805) 756-7354  tlmiller@calpoly.edu
Revised: 10/2013

Employee’s Request for Family and Medical Leave
This Form Is To be completed by the Health Care Provider:
Please provide the requested information below in relation only to the condition for which the employee is taking leave.
NOTE-T HE H EALTH C ARE P ROVIDER IS NOT TO DISCLOSE THE UNDERLYING DIAGNOSIS WITHOUT CONSENT OF THE PATIENT .
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, 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 an individual’s family member sought or received genetic services, and genetic information of a fetus 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.
1.
Employee’s Name: 2.
Patient’s Name (if other than employee):
3. On the reverse side is a description of what is meant by a “serious health condition” under both the federal and state family and medical leave laws. Does the patient’s condition qualify under any of the categories described? No Yes, If yes, please check the appropriate category below:
______ Inpatient care
______ Pregnancy
______ Chronic condition requiring treatments
______ Absence plus treatment
_____ Permanent/long-term condition requiring supervision
_____ Multiple treatments (non-chronic condition)
4. Date medical condition or need for treatment commenced
(mm/dd/yyyy):
5. Probable duration of medical condition or need for treatment
(mm/dd/yyyy):
6. If the certification is for the serious health condition of the employee, please answer the following:
a. YES NO Is employee able to perform work of any kind? (If “No” skip next question)
b. YES 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). (attach separate sheet if more room needed)::
______________________________________________________________________________________________________
______________________________________________________________________________________________________
7. Please answer the following question only if the employee is asking for
a. YES intermittent leave or reduced work schedule:
NO Is it medically 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 family member?
If YES, please indicate estimated number of doctor’s visits, and/or estimated duration of medical treatment, either by the health care practitioner or another provider of health services, upon referral from the health care provider (attach separate sheet if more room needed):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8. If the certification is for the care of the
a. YES employee’s family member , please answer the following:
NO Does (or will) the patient require assistance for basic medical, hygiene, nutritional needs, safety or transportation?
b. YES NO After review of the employee’s signed statement (or verbal conversation), 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.)
9. Estimate period of time care needed or during which employee’s presence would be beneficial:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Name of Health Care Provider (please print): Signature of Health Care Provider:
Type of Practice:
Address:
Date:
Telephone Number:
( )
Physician Instructions – Please complete and return to: Human Resources, Cal Poly State University, Attention Terizza Miller
Disability Programs Analyst, Building 001-110, San Luis Obispo, CA 93407-0020 PH: (805) 756-7354 FX: (805) 756-5483