EMPLOYEE: COMPLETE THE FOLLOWING (top of this page only) 2026

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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 employees to provide personal information, details about their health condition, and authorization for their health care provider to share relevant medical information. Health care providers must confirm the employee's health status, treatment details, and any necessary accommodations for returning to work.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the 'Employee’s Name' field. Ensure that you print clearly for easy readability.
Next, provide your Employee Number and Health Insurance Provider along with your Member Number.
Fill in your Work Location and Job Title accurately to reflect your current position.
Indicate whether the health condition is claimed as 'Serious' under FMLA by selecting 'yes' or 'no'. Specify if the leave is for yourself or a family member.
If applicable, describe the care you will provide for a family member, including an estimate of the care period and any intermittent work schedule.
Sign and date the authorization statement confirming that you agree to its terms. If applicable, include the family member's name and relationship.

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What is an authorized representative for I-9 verification?

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.

What should I put for the title of authorized representative?

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.

What is an authorized representative name?

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person.

Who completes section 2 of i9?

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).

Does everyone have to fill out an I-9 form?

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.

What does name of Authorised representative mean?

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.

Can an employer complete an I-9 before the start date?

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.

EMPLOYEE: COMPLETE THE FOLLOWING (top of this page only) 2026

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EMPLOYEE: COMPLETE THE FOLLOWING (top of this page only) 2026

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Got questions?

What is an authorized representative for I-9 verification?

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What is an authorized representative name?

Who completes section 2 of i9?

Does everyone have to fill out an I-9 form?

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