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Form Fml 501 - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 2

3. Use the information provided by the employer to answer this question. If the employer fails to provide a list of

the employee’s essential functions or a job description, answer these questions based upon the employee’s own

description of his/her job functions.

Is the employee unable to perform any of his/her job functions due to the condition: _____ No _____ Yes.

If so, identify the job functions the employee is unable to perform:

_______________________________________________________________________________________

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such

medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of

specialized equipment):

NOTE: In California, do not disclose the underlying diagnosis unless you have received consent from the patient

______________________________________________________________________________________________

________________________________________________________________________________________________

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? _____ No _____ Yes.

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? _____ No _____ yes.

If so, are the treatments or the reduced number of hours of work medically necessary? _____ No _____ Yes.

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: __________ hour(s) per day;

__________ days per week from _______________ through _______________

FML 501

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Form Fml 501 - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 2