Request For Formal Leave Of Absence Form - California State University Fullerton Page 6
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18PART A: MEDICAL FACTS
1. Approximate date condition commenced:
Probable duration of condition:
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes If so, dates of admission:
No
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition?
No
Yes
Was medication, other than over-the-counter medication, prescribed?
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
If so, expected delivery date:
3. Use the information provided by the employer in Section I to answer this question. If the employer fails
to provide a list of the employee’s essential functions or a job description, answer these questions
based upon the employee’s own description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition:
No
Yes
If so, identify the job functions the employee is unable to perform:
4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks
leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment
such as the use of specialized equipment):
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