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Forms

  • Overview
  • Family & Medical Leaves
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Family Medical Leave

  • FML Form 1 Employee Request(PDF – 123kb) *
  • FML Form 2 Cert of HC Provider – EE & Family(PDF – 133kb) *
  • FML Form 3 Cert of HC Provider – Servicemember (PDF – 136kb) *
  • FML Form 4 Cert for Military Family Leave(PDF – 128kb) *

Medical Release

  • Consent to Release Family Member’s Medical Information- FML(PDF – 47kb) *
  • Consent to Release Medical Information (PDF – 47kb) *
  • Consent to Release Personnel and Medical Information- FFD (PDF – 48kb) *

Reasonable Accommodations

  • RA Form 1 Request for RA Applicant(PDF – 91kb) *
  • RA Form 2 Request for RA Employee (PDF – 100kb) *
  • RA Form 3 Release of Information Consent (PDF – 60kb) *
  • RA Form 4 Work Status Report (PDF – 136kb) *
  • RA Form 6 RA and Interactive Process Overview (PDF – 97kb) *
  • RA Form 7 RA Declination Waiver(PDF – 97kb) *
  • RA Form 8 Request for RA Assistance(PDF – 97kb) *
  • RA Form 9 Countywide Job Search Referral(PDF – 97kb) *

Temporary Modified Work

  • Temporary Modified Work Plan (PDF – 97kb) *

Lakeside Plaza Building
1405 Lakeside Drive, Oakland, CA 94612-4305
Phone: 510.272.6471
Fax: 510.272.6424

Employment and Income Verification for employees are completed through The Work Number at 1-800-367-5690 or www.theworknumber.com (employer code: 14630).

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