How to Fill Out and Submit the CFRA Medical Certification Form

The CFRA medical certification form is the document your healthcare provider completes to confirm that you or a qualifying family member has a serious health condition, so your time off is protected under the California Family Rights Act. The official version is form CRD-E11P-ENG, “Certification of Health Care Provider,” published as a downloadable PDF by the California Civil Rights Department.¹ Your employer may give you a different form instead. You fill in a short employee section, your provider completes the medical portion, and you return the finished form to your employer within 15 calendar days of being asked.

Where to Get the Form

Download the standard form directly from the California Civil Rights Department (formerly the Department of Fair Employment and Housing) as a PDF titled “Certification of Health Care Provider,” designation CRD-E11P-ENG.¹

Your employer is allowed to hand you a proprietary form instead under 2 CCR § 11097. The substitute cannot demand more information than California regulations authorize, and it cannot require your provider to disclose the underlying diagnosis without your consent.² If an employer form asks for your specific diagnosis in a mandatory field, that’s a red flag. Push back.

Who Is Qualified to Sign It

Not every medical professional counts. Under CFRA regulations, a “health care provider” means a physician, surgeon, or osteopathic physician licensed in California or another jurisdiction who directly treats or supervises treatment of the serious health condition. The definition also picks up anyone who meets the federal FMLA definition of someone capable of providing health care services, including nurse practitioners, nurse-midwives, clinical psychologists, clinical social workers, and other practitioners authorized under state law and practicing within their scope.³

The provider who signs should be the one actually treating the condition. A certification from someone with no direct role in the treatment is easier for an employer to challenge.

What Goes on the Form

The fields come from 2 CCR § 11097 and match the certification requirements in Government Code § 12945.2.⁴ Some sections are yours; the rest belong to your provider.

Employee Section

You fill in your name, the patient’s name if the leave is to care for someone else, and the patient’s relationship to you. If you’re caring for a “designated person” rather than a traditional family member, you identify them here. A designated person is anyone related to you by blood or whose relationship with you is the equivalent of a family relationship, such as a close friend. Employers can limit you to one designated person per 12-month period.⁵

When the leave is to care for someone else, you also complete a statement at the end of the form describing the care you’ll provide and estimating how long you’ll provide it. Attach a schedule if the leave will be intermittent.

Provider Section: Leave for Your Own Condition

If the leave is for your own serious health condition, the statute requires the certification to include:⁶

The date the condition began.
The probable duration of the condition.
A statement that you’re unable to perform at least one essential function of your job because of the condition.

The form also asks whether you’re able to perform work of any kind. Your provider does not need to name the diagnosis. The form explicitly notes that the healthcare provider should not disclose the underlying diagnosis without the patient’s consent.⁴ What matters is the functional impact, not the medical label.

Provider Section: Leave to Care for a Family Member

When you’re caring for a family member or designated person, the certification must include:⁶

The date the condition began.
The probable duration.
An estimate of the time the provider believes you need to give care.
A statement that the serious health condition warrants your participation during a period of treatment or supervision.

The provider is asked whether the patient needs help with basic medical needs, hygiene, nutrition, safety, or transportation, and to confirm that your care statement in the employee section is warranted by the condition.

Intermittent or Reduced-Schedule Leave

If you need periodic absences rather than one continuous block, the form has a dedicated section your provider must complete. The provider should give estimated frequency and duration of episodes, for example, “one episode every three months lasting one to two days.” For a reduced work schedule, the provider specifies the part-time hours or reduced schedule you need. The form also asks whether time off for medical appointments is necessary and, if so, how often and how long each visit takes, including recovery time.⁴

Vague answers cause problems here. “As needed” without any frequency estimate gives your employer grounds to reject the certification as insufficient. Coach your provider to be specific.

Submitting the Form

You have 15 calendar days from the date your employer requests certification to deliver the completed form. If that’s not practically possible despite a good-faith effort, say because your provider is unavailable, the deadline can flex, but you need a legitimate reason. Your employer must tell you upfront what happens if you fail to return a complete certification in time.⁷

Your leave can begin before the employer receives the certification; the 15-day window does not delay your start date. But if you miss the deadline without good cause, the employer can deny CFRA protections for the leave period that follows until you produce a sufficient certification. If you never produce one, the leave simply is not CFRA-protected.⁷

Deliver the form in a way that creates a paper trail. Certified mail with return receipt, email with a read receipt, or hand delivery with a signed acknowledgment all work. If a dispute arises later about whether you submitted on time, you want documentation.

If the Certification Is Incomplete

If the form is incomplete or does not contain enough information, your employer must notify you in writing about what’s missing and give you an opportunity to fix it. The CFRA regulations don’t specify a separate cure period beyond the original 15-day window; they require only that the employer explain the deficiencies and advise you of the consequences of not providing adequate certification.⁷ Get corrections made quickly. Your CFRA protections are at stake for every day that passes without a sufficient certification on file.

What Your Employer Can Do After Receiving the Form

Authentication Only

Your employer can contact the healthcare provider, but only to authenticate the certification, meaning to confirm the provider actually completed and signed the document. They cannot use that contact to dig for additional medical information such as symptoms, a diagnosis, or treatment details.⁸ The regulation draws a hard line: authentication, nothing more. Unlike the federal FMLA, CFRA does not permit the employer to seek clarification from your provider beyond verifying the document is genuine.

Second and Third Opinions

If your employer has a good-faith, objective reason to doubt the validity of your certification for your own serious health condition, they can require you to see a second healthcare provider at the employer’s expense. The employer picks this provider, but it cannot be someone who works for them on a regular basis.⁶

If the second opinion disagrees with the original, the employer can require a third opinion, again at the employer’s cost. You and the employer jointly select the third provider, and that third opinion is final and binding on both sides regardless of what the first two providers said. The second-and-third-opinion process applies only to leave for your own condition. For leave to care for a family member, the employer can authenticate the certification but cannot require a second opinion under CFRA. You’re entitled to copies of the second and third opinions at no cost if you request them.⁸

Medical Privacy

The employer cannot require your provider to disclose the underlying diagnosis without your consent.² They also cannot ask you for additional medical information beyond what the regulations allow, and any medical information they do receive is subject to applicable confidentiality laws.⁸ Your completed certification should be stored separately from your general personnel file, with access limited to HR staff or managers who have a real need to see it.

Recertification

Your employer can ask for a new certification when the time period your provider originally estimated has expired and you need more leave. That’s the trigger, not an arbitrary calendar interval. If your provider estimated six weeks and you request additional time after those six weeks, expect a recertification request. The same 15-day submission rule and form requirements apply.⁸

Return-to-Work Certification

When your leave was for your own serious health condition, your employer can require a release to return to work stating you’re able to resume your duties, but only if they have a uniformly applied policy of requiring return-to-work releases from all employees coming back from illness, injury, or disability. A policy that singles out CFRA leave-takers does not qualify.⁸

If you were on intermittent leave, the employer generally cannot demand a release for each individual absence. The one exception: if reasonable safety concerns exist about your ability to perform your duties, the employer can request a release up to once every 30 days.⁸

CFRA also prohibits employers from requiring a full fitness-for-duty examination as a condition of returning from leave. Once you’re back, any medical examination must be job-related and consistent with business necessity under California’s fair employment regulations; it cannot be a blanket requirement triggered by the leave itself.⁸

1
California Civil Rights Department. Certification of Health Care Provider
2
Legal Information Institute. California Code of Regulations Title 2, 11097 – Certification Form
3
Legal Information Institute. California Code of Regulations Title 2, 11087 – Definitions
4
New York Codes, Rules and Regulations. California Code of Regulations 11097 – Certification Form
5
New York Codes, Rules and Regulations. California Code of Regulations 11087 – Definitions
6
California Legislative Information. California Government Code 12945.2
7
New York Codes, Rules and Regulations. California Code of Regulations 11091 – Requests for CFRA Leave
8
Legal Information Institute. California Code of Regulations Title 2, 11091 – Requests for CFRA Leave