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Fmla medical certification form

Form I - Non FMLA Certification - Family Members Health Condition 2026

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The document is a Non-FMLA Certification of Health Care Provider form designed for employees seeking leave to care for a family member with a serious health condition. It includes sections for the employer, employee, and health care provider to complete, detailing the relationship between the employee and the family member, the nature of care required, and medical information regarding the family member's condition. The form emphasizes compliance with the Genetic Information Nondiscrimination Act (GINA) by prohibiting the inclusion of genetic information.

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Click ‘Get Form’ to open it in the editor.
In Section II, enter your name and the name of the family member you will care for. Specify your relationship and, if applicable, their date of birth.
Describe the care you will provide and estimate the leave needed. Be detailed to ensure clarity.
Sign and date the form at the bottom of Section II before passing it to your family member's health care provider.
In Section III, ensure that the health care provider fills out all relevant medical information, including treatment dates and necessary care details.
Review all sections for completeness before submitting. Make sure all signatures are present.

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What is a non FMLA?

Personal Medical Leave (Non-FMLA/Non-CFRA) provides eligible staff employees with up to twelve (12) weeks in a 12-month period (measured backward on a rolling basis) of unpaid time away from work for their own serious health condition.

Can you say someone is on FMLA?

As a general rule, an employees health and other information is confidential. Therefore, you should not disclose any confidential information to other employees. However, you may provide general information and you may tell others that an employee is out of the office on a leave of absence.

What to write on FMLA?

1. FMLA Form WH-380-E for Employee Health Condition When your condition began. The best estimate of how long it can last. Whether the condition has required an overnight stay in a medical facility. The job duties that your condition prevents you from providing. Symptoms, diagnosis, and treatment plan.

Is anxiety a serious health condition for FMLA?

A chronic condition whether physical or mental (e.g., rheumatoid arthritis, anxiety, dissociative disorders) that may cause occasional periods when an individual is unable to work is a qualifying serious health condition if it requires treatment by a health care provider at least twice a year and recurs over an

Who is considered an immediate family member under the Family and Medical Leave Act for purposes of taking FMLA leave?

To care for an immediate family member (i.e., spouse, child, or parent) with a serious health condition; or.

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How do you describe the care you will provide to your family member?

Helping the family member with daily tasks they cant do themselves, such as helping them get dressed or preparing meals. Providing transportation to the doctor for appointments and treatment. Helping make arrangements for changes in care, such as a transfer to a nursing home.

What to write on FMLA paperwork for family members?

Youll need to know: Their name and relationship to you. The type of care youre providing and how much time off you need.