Request For Formal Leave Of Absence Form - California State University Fullerton Page 11
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18PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need for
care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or
transportation needs, or the provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and
recovery?
No
Yes
Estimate the beginning and ending dates for the period of incapacity:
During this time, will the patient need care?
No
Yes
Explain the care needed by the patient and why such care is medically necessary:
5. Will the patient require follow-up treatments, including any time for recovery?
No
Yes
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment, including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?
No
Yes
Estimate the hours the patient needs care on an intermittent basis, if any:
hour(s) per day;
days per week
from
through
Explain the care needed by the patient, and why such care is medically necessary:
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