Equal Employment Opportunity (Eeo) Policy And Program Administration Form Sample Page 40

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VA MEDICAL CENTER
POLICY MEMORANDUM 00-304
BRONX, NEW YORK 10468
July 31, 2003
D. If a regimen of continuing treatment by the patient is required under your supervision, provide a general
description of such regimen (e.g., prescription drugs, physical therapy requiring special equipment, etc.):
_________________________________________________________________________________________________
7. A. If medical leave is required for the employee’s absence from work because of the employee’s own condition
(including absences due to pregnancy or a chronic condition), is the employee unable to perform work of any
kind?
Yes
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 (the employee or the employer should provide you with information about the essential job
functions)?
Yes
No
If yes, please specifically list the essential functions the employee is unable to perform:
C. If neither 7.A nor B applies, is it necessary for the employee to be absent from work for treatment?
Yes
No. Explain:
_________________________________________________________________________________________________
8. A. If FMLA leave is required for the employee to care for a family member with a serious health condition, does
the patient require assistance for basic medical or personal needs or safety, or for transportation?
Yes
No
B. If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in
the patient’s recovery?
Yes
No. Explain:
C. If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of
this need:
To be completed by Health Care Provider
______________________________________________
_____________________________
(Signature of Health Care Provider)
(Type of Practice)
______________________________________________
_____________________________
(Address)
(Telephone Number)
_______________________________________________
_____________________________
(Date )
To be completed by the employee needing FMLA leave to care for a family member
State the care you will provide and an estimate of the period during which care will be provided, including a schedule if
leave is to be taken intermittently or if it will be necessary for you to work less than a full-time schedule:
_____________________________________________
__________________
(Employee Signature)
(Date)
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