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3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care

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

the use of specialized equipment):

NOTE: In California and Connecticut, do not disclose the underlying diagnosis unless you have received

consent from the patient

__________________________________________________________________________________________

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need

for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or

transportation needs, or the provision of physical or psychological care:

4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and

recovery? _____No _____Yes.

Estimate the beginning and ending dates for the period of incapacity: _________________________________

During this time, will the patient need care? _____No _____Yes.

Explain the care needed by the patient and why such care is medically necessary:

_________________________________________________________________________________________

5. Will the patient require follow-up treatments, including any time for recovery? _____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:

_________________________________________________________________________________________

Explain the care needed by the patient, and why such care is medically necessary:

_________________________________________________________________________________________

6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?

_____No _____Yes.

Estimate the hours the patient needs care on an intermittent basis, 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 Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 3