An Administrator's Guide to California Private School Law Compendium

D OCUMENT 8.F

S AMPLE M EDICAL C ERTIFICATION – E MPLOYEE ’ S F AMILY M EMBER ’ S S ERIOUS H EALTH C ONDITION

1. Employee’s Name:___________________________________________________ 2. Patient’s Name:______________________________________________________ 3. Does the employee’s child, parent, spouse, or domestic partner have an illness, injury, impairment, or physical or mental condition which constitutes a “serious health condition?” A “serious health condition” is described on the attached sheet. Does the patient’s condition qualify under any of the categories described? If so, please check the applicable category. (1)___ (2)___ (3)___ (4)___ (5)___ (6)___ or None of the above____. If employee will be caring for an adult child, a health care provider must certify the following: Patient is Employee’s Adult Child Patient is Incapable of Self Care** ___________________________ ___________________________ Signature of Health Care Provider Signature of Health Care Provider 4. Date medical condition or need for treatment commenced:____________________ 5. Probable duration of medical condition or need for treatment:_________________ 6. Does (or will) the patient require assistance for basic medical, hygiene, nutritional needs, safety or transportation? 7. After review of the employee’s signed statement (See Item 10 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 family member.)  Yes  No

An Administrator’s Guide to California Private School Law - Compendium ©2019 Liebert Cassidy Whitmore 114