Request For Formal Leave Of Absence Form - California State University Fullerton Page 12
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187. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily
activities?
No
Yes
Based upon the patient's medical history and your knowledge of the medical condition, estimate the frequency of
flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode
every 3 months lasting 1-2 days):
Frequency:
times per
week(s)
months(s)
Duration:
hours or
day(s) per episode
Does the patient need care during these flare-ups?
No
Yes
Explain the care needed by the patient, and why such care is medically necessary:
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDTIONAL ANSWER.
Signature of Health Care Provider
Date
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DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
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