2.
Is the medical condition pregnancy? _____ No _____ Yes
If so, expected delivery date: _________________________________
3.
Answer the following questions based upon the employee’s 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):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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: From:_________________ To:__________________
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 _______________
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)
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________
________________________________
Signature of Health Care Provider
Date
Revised 02/2016