Request For Formal Leave Of Absence Form - California State University Fullerton Page 10
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18SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care
for your patient. Answer, fully and completely, all applicable parts below. Several questions seek a response as to the frequency
or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge,
experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate”
may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Do
not provide information about generic tests, as defined in 29 C.F.R § 1635.3(f), or generic services, as defined in 29 C.F.R §
1635.3(e). Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page.
Provider's name and business address:
Type of practice / Medical specialty:
Telephone:
Fax:
PART A: MEDICAL FACTS
1. Approximate date condition commenced:
Probable duration of condition:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
If so, dates of admission:
No
Yes
Date(s) you treated the patient for condition:
Was medication, other than over-the-counter medication, prescribed?
No
Yes
Will the patient need to have treatment visits at least twice per year due to the condition?
No
Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g. physical therapist)?
Yes If so, state the nature of such treatments and expected duration of treatment:
No
2. Is the medical condition pregnancy?
No
Yes
3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of
specialized equipment):
CONTINUED ON NEXT PAGE
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