City Of Dallas Family Medical Leave Application Form (Page 4 of 5) in pdf

City of Dallas

FAMILY MEDICAL LEAVE APPLICATION

HEALTHCARE PROVIDER CERTIFICATION – Part II (Continued)

(The treating physician is responsible for completing this section.)

Employee Name:

Patient's Name (If Different):

6. Multiple Treatments (Non-chronic Conditions)

Any period of absence to receive multiple treatments (including any period of recovery) by a healthcare provider or by a

provider of healthcare services under orders of, or on referral by, a healthcare provider, either for restorative surgery after

an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive

calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe

arthritis (physical therapy) and kidney disease (dialysis).

* Family Medical Leave approvals are contingent upon the employee meeting the eligibility requirements for Family Medical

Leave.

** Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition.

Treatment does not include routine physical examinations, eye examinations, or dental examinations.

*** A regimen of continuing treatment includes a course of prescription medicine (e.g., an antibiotic) or therapy requiring

special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-

the-counter medications such as aspirin, antihistamines, salves, bed-rest, drinking fluids, exercise, and/or other similar

activities that can be initiated without a visit to a healthcare provider.

**** “Incapacity” for purposes of Family Medical Leave is defined to mean inability to work, attend school, or perform other

regular daily activities due to the serious health condition, treatment thereof, or recovery there from.

Condition/Treatment/Duration

(The treating physician is responsible for completing this section.)

(Employees may be asked to provide additional medical documentation to support absences that vary from listed dates.)

1. a. Date condition began: ____/____/______

b. Probable duration of the patient’s present incapacity: From: ____/____/______ to: ____/____/______

c. Probable duration of employee’s Family Medical Leave: From: ____/____/_____ to: ____/____/______ including any

expected follow-up.

2. Will it be necessary for the employee to work only intermittently or to work on a less than full schedule as a result of the

condition?

YES

If YES, give the probable duration and/or hours per day employee can work:

_________________________________________________________________________________________________

3. If the condition is a chronic condition or pregnancy, state the likely duration and frequency of episodes of incapacity****:

________________________________________________________________________________________________

4. If a regimen of continuing treatment by the patient is required, provide a general description of such regimen (e.g.,

prescription drugs, physical therapy requiring special equipment):

_________________________________________________________________________________________________

________________________________________________________________________________________________

“Dallas, the City that Works: Diverse, Vibrant and Progressive”

HRD Form Rev.June 2006

City Of Dallas Family Medical Leave Application Form Page 4