Nc State University Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 3

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Certification of Health Care Provider for
Employee's Serious Health Condition
(Family and Medical Leave Act)
PART B: AMOUNT OF LEAVE NEEDED
5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,
including any time for treatment and recovery?
Yes
No
If so, estimate the beginning and ending dates for the period of incapacity:
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced
schedule because of the employee's medical condition?
Yes
No
If so, are the treatments or the reduced number of hours of work medically necessary?
Yes
No
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time
required for each appointment, including any recovery period:
Estimate the part-time or reduced work schedule the employee needs, if any:
hours(s) per day;
days per week
through
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job
functions?
Yes
No
Is it medically necessary for the employee to be absent from work during the flare-ups?
Yes
No
If so, explain:
Based upon the patient's medical history and your knowledge of the medical condition, estimate the frequency
of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g. 1
episode every 3 months lasting 1-2 days):
Frequency:
times per
week(s)
month(s)
Duration:
hours or
day(s) per episode
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
CONTINUED ON NEXT PAGE
Questions about this form? Contact Leave Administration at (919) 515-2151
Page 3 of 4
Revised: May 2015

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