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Form Fml 501 - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 3

7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job

functions? _____ No _____ Yes.

Is it medically necessary for the employee to be absent from work during the flare-ups? _____ No _____ Yes.

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

*Important: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered

by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except

as specifically allowed by this law. To comply with this law, we are asking you and your health care provider not to provide

any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA

includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an

individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by

an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving

assistive reproductive services.

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

_________________________________________________________________________________________

______________________________________

_________________________________________

Signature of Health Care Provider

Date

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 3