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

City of Dallas

FAMILY MEDICAL LEAVE APPLICATION

Condition/Treatment/Duration (Continued)

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

4a. If the employee will be absent from work because of treatment on an intermittent or part-time basis, provide:

1) an estimate of the probable number of treatments: ________________________________________________

2) interval(s) between such treatments: ___________________________________________________________

3) actual or estimated dates of treatment, if known: __________________________________________________

4) period required for recovery, if any: ____________________________________________________________

b. If any treatment will be provided by another provider of health services (e.g., physical therapist), please state the

nature of the treatment:

_________________________________________________________________________________________________

5 . If leave is required to care for a family member of the employee with a serious health condition:

a. Does the patient require assistance for basic medical or personal needs, or for transportation?

YES

b. If no, is the employee’s presence necessary for the patient’s psychological comfort or to assist in the patient’s

recovery?

YES

c. Will the patient need care only intermittently or on a part-time basis?

YES

If yes, please indicate the probable duration of this need: _____________________________

HEALTHCARE PROVIDER CERTIFICATION

______________________________________

________________________________

________________________

(Original Signature of Healthcare Provider)

(Please Print Name)

(Type of Practice)

____________________________________

________________________________

________________________

(Address)

(City, State, Zip Code)

(Telephone No.)

____________________________________

_________________________________

_______________________

(State Licensing/Certifying Agency)

(License/Certificate No.)

(Date)

The City of Dallas reserves the right to revise the FML form as needed to comply with city policies and/or local, state and

federal laws, regulations and guidelines. Employees do not have the right to modify or change this form. Revised 11/06

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

HRD Form Rev.June 2006

City Of Dallas Family Medical Leave Application Form Page 5