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California Employee Medical Certification Form

Author: Katherine Hinde, Littler

When to Use

A California employer may use this form if it requires an employee to provide a medical certification supporting a request to take leave for the employee's own medical condition under the federal Family and Medical Leave Act (FMLA), the California Family Rights Act (CFRA) and/or California's pregnancy disability leave law.

Employer coverage under these laws are as follows:

  • The FMLA covers employers that employ 50 or more employees in 20 or more workweeks in the current or preceding calendar year that are engaged in commerce or in any industry or activity affecting commerce.
  • The CFRA covers employers that directly employ five or more employees.
  • California's pregnancy disability leave law covers employers that employ five or more full-or part-time employees, regardless of whether the employee's worksite is located within or outside of California.

Customizable Form