Form P33a - Employee Medical Certificate - 2011 Page 2
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4(c) If condition is a “chronic condition” (as checked off under Section (1)) or pregnancy, state
whether the patient is presently incapacitated and the likely duration and frequency of
episodes of incapacity:
____ Patient ____ is ____ is not presently incapacitated. (check one)
Going forward, estimate the:
____ Duration of episodes of incapacity = _______________ (hours or days, etc.)
____ Frequency of episodes of incapacity = ________ (no. of times per week or month, etc.)
(a) If additional treatments will be required for the condition and/or the patient will be absent
(4)
from work or other daily activities because of treatment on an intermittent or part-time basis,
provide:
____ An estimate of the probable number of such treatments. _______________________
____ An estimate of the probable interval between such treatments. _________________
____ An actual or estimated dates of treatment, if known. ___________________________
____ Period required for recovery, if any. _______________________________________
(b) If any of these treatments will be provided by another provider of health services (e.g.,
physical therapist), please state the nature of the treatment and period of time covered.
_________________________________________________________________________
_________________________________________________________________________
(c) If a regimen of continuing treatment by the patient is required under your supervision, provide
TO BE FILLED
a general description of such regimen (e.g., prescription drugs, physical therapy requiring
IN BY
special equipment). _________________________________________________________
ATTENDING
_________________________________________________________________________
PHYSICIAN OR
(5)
(a) During the period of incapacity, is the employee able to perform work of any kind?
PRACTITIONER
(Please print legibly.)
(fill in “yes” or “no”)
(b) If able to perform some work, is the employee unable to perform any one or more of the
essential functions of the employee’s job (if FMLA leave or if relevant, a job specification is
enclosed for your convenience)?
(fill in “yes” or “no”)
If yes, elaborate. ___________________________________________________________
_________________________________________________________________________
(c) If neither (4)(a) or (4)(b) applies, is it necessary for the employee to be absent from work for
treatment?
(fill in “yes” or “no”)
(6)
regular
selective work
The employee will be able to return to
or
on
__________________ (date). If selective work, explain under number (7) below.
Additional remarks:
(7)
Name of Physician or Practitioner AND Physician or Practitioner License Number (please type or print)
Address (No. and Street)
(City or Town)
(State)
(ZIP Code)
Signed (Physician or Practitioner)
Date
Telephone
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Parent category: Medical