Sonoma County Medical Certification for Family Members
This form is used by County of Sonoma employees for a leave of absence to care for a covered family member with a serious health condition. It meets the requirements of the California Family Rights Act and the federal Family Medical Leave Act. Complete Section I and then provide the form to the family member or their healthcare provider.
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How do I fill this out?
To fill out this form, begin by completing Section I with your details as the employee. Then, the family member or their healthcare provider should complete Section II. Ensure all required fields are filled out correctly to avoid delays.
How to fill out the Sonoma County Medical Certification for Family Members?
1
Complete Section I with employee's details.
2
Provide the form to the family member or healthcare provider.
3
Healthcare provider completes Section II.
4
Ensure all required fields are filled out.
5
Submit the form within 15 calendar days.
Who needs the Sonoma County Medical Certification for Family Members?
1
Employees applying for leave under CFRA or FMLA need this form.
2
Healthcare providers completing certification for an employee.
3
Family members who need care from an employee.
4
Human Resources for processing leave requests.
5
Employees needing to document a family member's serious health condition.
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What are the instructions for submitting this form?
Submit the completed form to the Human Resources department of Sonoma County. You can email it to HR@sonoma-county.org, fax it to (707) 565-3489, or mail it to: Sonoma County HR, 575 Administration Drive, Room 116 B, Santa Rosa, CA 95403. Ensure all sections are fully completed to avoid delays.
What are the important dates for this form in 2024 and 2025?
Submit the form within 15 calendar days from the date of request to avoid delays in your leave approval.
What is the purpose of this form?
The purpose of this form is to provide medical certification for a County of Sonoma employee requesting a leave of absence to care for a covered family member with a serious health condition. It ensures compliance with the California Family Rights Act (CFRA) and the federal Family Medical Leave Act (FMLA). This form is essential for documenting the medical necessity of the employee's leave request and facilitating the approval process.
Tell me about this form and its components and fields line-by-line.
- 1. Employee's Name: Enter the employee's first, middle, and last name.
- 2. Department: Specify the employee's department.
- 3. Authorization: The patient authorizes the healthcare provider to provide the requested information.
- 4. Health Care Provider Information: Details about the healthcare provider including name, type of practice, contact information.
- 5. Patient's Name: Enter the name of the patient.
- 6. Relationship: Specify the relationship of the patient to the employee.
- 7. Medical Condition Start Date: Enter the date the medical condition or need for treatment began.
- 8. Duration: Provide the probable duration of the health condition or treatment.
- 9. Type of Leave: Specify if the leave is continuous or intermittent.
- 10. Serious Health Condition Categories: Check the box that describes the patient's condition.
- 11. Employee Participation: Indicate if the condition warrants the participation of the employee.
- 12. Intermittent Leave: Provide details if intermittent leave or reduced work schedule is needed.
- 13. Additional Information: Include any additional information relevant to the leave request.
- 14. Signature of Health Care Provider: The healthcare provider must sign the form.
What happens if I fail to submit this form?
Failing to submit this form on time can delay or deny the approval of your leave request.
- Delay in Leave Approval: Processing of your leave request may be delayed without timely submission.
- Denial of Leave: Incomplete or late submission can result in denial of your leave request.
How do I know when to use this form?
- 1. Employee Family Leave Request: When an employee needs leave to care for a covered family member.
- 2. Healthcare Provider Certification: For healthcare providers to certify the medical condition of the family member.
- 3. Intermittent Leave: When the leave is required intermittently or on a reduced schedule.
- 4. Human Resources Processing: For HR to document and approve the leave request.
- 5. Legal Compliance: To comply with CFRA and FMLA requirements for family medical leave.
Frequently Asked Question
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Use PrintFriendly's editor to fill in and adjust information as needed.
Can I sign the document?
Yes, use our digital signature tool to add your signature.
How do I share the completed form?
Email the document or generate a shareable link from PrintFriendly.
Is the form compatible with CFRA and FMLA requirements?
Yes, this form meets the requirements of both CFRA and FMLA.
Can healthcare providers edit the PDF?
Healthcare providers can use PrintFriendly to complete Section II of the form.
When do I need to return the completed form?
Submit the form within 15 calendar days to avoid delays.
What if I need to take leave intermittently?
Indicate the need for intermittent leave or a reduced schedule in the form.
Who should sign the form?
The patient and healthcare provider must sign the form.
Can I save a partially completed form?
Yes, use PrintFriendly to save your progress and continue later.
Do I need to complete all sections?
Ensure all required fields in Sections I and II are completed.
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Sedgwick County Family Medical Leave Request Form
This file is the Sedgwick County Family Medical Leave Request Form. It is to be completed by the employee requesting leave under the Family Medical Leave Act. Required fields include employee information and reason for leave.
