Formulario De Certificion Del Estado De Colorado Empleados Con Condiciones Graves De Salud - Colorado Division Of Human Resources Page 3

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Formulario de Certificion Del Empleados
Con Condiciones Graves de Salud
(Family and Medical Leave Act)
Page 3
Revised May 2015
Continued on Next Page
Expires 5/31/2018
PARTE B: TIEMPO NECESITADO
Estara el empleado incapacitado por un periodo continuo debido a su condicion incluyendo cualquier tiempo de
tratamiento y recuperacion. ______Si ______No.
Si es haci, calcule el principio y final de las fechas de incapcidad:__________________________________________
Tendra el empleado que asistir citas para seguimiento o trabajar tiempo parcial o un horario reducido por la
condicion medica? _____Si _____No.
Si es haci, hay tratamientos o horas reducidas necesarias debido a la necesidad medica? _____Si _____No.
Horario estimado de tratamiento, si hay alguno, incluyendo las fechas de cualquier cita or citas el tiempo
requerido para cada cita, incluyendo el periodo de recuperacion: __________________________________________
Estime el tiempo parcial o tiempo reducido que el empleado/a necesite, si alguno______ hora(s) por dia; ________
dias por semana de_______________ hasta______________.
Causara la condicion de el empleado episodios periodicamente prevenidos por el empleado de hacer sus funciones
laborales _____Si _____No.
Es medicamente necesario para el empleado/a estar usente durante estos episodios si llegaran a suceder? ____Si
____No. ___________________________________________________________________________________________
Basado en el histotial medico de el paciente y su conocimiento la condidion medica, estime la frecuencia de los
episodios y la duracion the la incapacidad que el paciente tendra sobre los siguientes 6 meses (por ejenplo, un
episodio cada 3 meses, durara 1-2 dias)
Frecuencia_____ veces por_____ semana(s)_____ meses
Duracion_____ hora(s)o_____ dias por episodio.
Informacion adicional :
___________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Firma de el proveedór de salúd: _________________________________ Fecha: _____________________
Nombré en letrá de molde: _______________________________________________________
Revised May 2015
Expires 5/31/2018
1525 Sherman St., Denver, CO 80203 P 303.866.5652
John W. Hickenlooper, Governor | June Taylor, Executive Director

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