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To comply with CalGINA, we are asking that you not provide any genetic information when responding to this request for medical information.“Genetic Information,” as defined by CalGINA, includes information about the individual’s or the individual’s family member’s genetic tests, information regarding the manifestation of a disease or disorder in a family member of the individual, and includes information from genetic services or participation in clinical research that includes genetic services by an individual or any family member of the individual.“Genetic Information” does not include information about an individual’s sex or age.  \n1. Employee Name:    \n2. Patient’s Name (if other than employee):   Is patient the employee’s family member (i.e., child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, domestic partner, or designated person)?  \nNote: “child” includes a biological, adopted, foster child, a stepchild, a legal ward, a child of the employee’s domestic partner, and a person to whom the employee stands in loco parentis.“Parent” includes a biological, foster, or adoptive parent, a parent-in-law, a stepparent, a legal guardian, or other person who stood in loco parentis to the employee when the employee was a child. A biological or legal relationship is not necessary for a person to have stood in loco parentis to the employee as a child.“Designated person” means any individual related by blood or whose association with the employee is the equivalent of a family relationship.  Yes  No  \n3. Date medical condition or need for treatment commenced [NOTE: THE HEALTH CARE PROVIDER IS NOT TO DISCLOSE THE UNDERLYING DIAGNOSIS WITHOUT CONSENT OF THE PATIENT]:  \n4. Probable duration of medical condition or need for treatment:    \n5. Below is a description of what constitutes a “serious health condition” under both the  Yes  No federal Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA) .  \nDoes the patient’s condition qualify as a serious health condition?  \n6. If the certification is for the serious health condition of the employee, please answer the following:  \nIs the employee able to perform work of any kind? (If “No,” skip next question)  Yes  No  \nIs employee unable to perform any one or more of the essential functions of employee’s  Yes  No  \nposition? (Answer after reviewing statement from employer of essential functions of  \nemployee’s position, or, if none provided, after discussing with employee. )  \n7. If the certification is for the care of the employee’s family member, please answer the following:  \nDoes (or will) the patient require assistance for basic medical, hygiene,  Yes  No  \nnutritional needs, safety, or transportation?  \nAfter review of the employee’s signed statement (see item 10 below), does the  Yes  No  \ncondition warrant the participation of the employee? (This participation may include psychological comfort and/or arranging for third-party care for the family member. )  \nCRD-E11P-ENG / January 2023 / Page 1  \n8. Estimate the period of time care is needed or during which the employee’s presence would be beneficial:  \n9. Please answer the following questions only if the employee is asking for intermittent leave or a reduced work schedule:  \nIntermittent Leave: Is it medically necessary for the employee to be  Yes  No  \noff work on an intermittent basis due to the serious health condition  \nof the employee or family member?  \nIf yes, please indicate the estimated frequency of the employee’s need for intermittent leave due to the serious health condition, and the durat","cbCailSSrORfBP1d","https://ap.wps.com/l/cbCailSSrORfBP1d","pdf",306807,"English","# Certification of Health Care Provider\n## Patient and Employee Information\n## Medical Condition Details\n## Serious Health Condition Eligibility\n## Care and Participation Questions\n## Leave Schedule and Appointment Needs\n## Employee Statement and Signatures","[{\"question\":\"What genetic information is prohibited from being provided on this form?\",\"answer\":\"The form states that genetic information must not be provided in response to the medical information request, except as specifically allowed by law under CalGINA. It defines genetic information to include genetic tests and related disease manifestation information within a family, but not sex or age.\"},{\"question\":\"What information does the employee and provider need to complete?\",\"answer\":\"It requests the employee name and, if different, the patient’s name, whether the patient is the employee’s family member as defined, the medical condition start date, probable duration, and whether the condition qualifies as a serious health condition under CFRA/FMLA.\"},{\"question\":\"When is the form asking about intermittent leave or a reduced schedule?\",\"answer\":\"It asks only if the employee is requesting intermittent leave or a reduced work schedule. It then requests estimated frequency and duration for intermittent leave, and the reduced part-time work schedule details if applicable.\"}]","CFRA Certification of Health Care Provider for California Family Rights Act (CFRA) or Family and Medical Leave Act (FMLA) - Complete Form | PDF",1789970810]