EMPLOYEE: COMPLETE THE FOLLOWING (top of this page only) 2025

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The document is a Certification of Health Care Provider form from the Los Angeles Unified School District's Human Resources Division. It is designed for employees to request leave under the Family and Medical Leave Act (FMLA) due to serious health conditions affecting themselves or family members. The form requires detailed information about the employee, their health condition, treatment details, and verification from a healthcare provider. It outlines the definitions of 'serious health condition' and provides instructions for submission.
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An I-9 authorized representative is someone designated by your company who can fill out and sign Form I-9 (Employment Eligibility Verification) on your behalf. An authorized representative can be especially helpful if you cant be physically at the location where new employees are being onboarded.
Title of Employer or Authorized Representative Enter your title, position or role with your business or organization. Last Name of the Employer or Authorized Representative Enter your full legal last name. First Name of the Employer or Authorized Representative Enter your full legal first name.
Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person.
As an employer, you or your authorized representative must complete and sign Section 2 of Form I-9, Employment Eligibility Verification, within 3 business days of the date of hire of your employee (the hire date means the first day of work for pay).
All employers must complete and retain Form I-9, Employment Eligibility Verification, for every person they hire for employment after Nov. 6, 1986, in the U.S. as long as the person works for pay or other type of payment.

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An Authorized Representative is an individual with legal authority to bind the government entity (e.g., the Chief Executive Officer of the government entity). An Authorized Representative must sign the Acceptance of Award terms for it to be valid.
The Form I-9 can be completed as soon as the job offer has been extended and accepted. Newly hired employees must complete and sign Section 1 of Form I-9 no later than their first day of employment. You may not use the Form I-9 process to screen job applicants or to delay the actual start day of work.

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Sample Policies and Procedures

We provide a complete Employee Manual, or you can download individual policies. You can also enter in a search at the top of the navigator in the sample form.

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COMPLETING FORM I-9

➢ Write employee R# at the top of page. ➢ Ensure employees name is written in space provided. ➢ Complete only. Section 3 for reverifications.

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Completing Section 1, Employee Information and Attestation

Jan 25, 2025 Your employees must complete and sign Section 1 of Form I-9 no later than their first day of employment.

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