Request For Formal Leave Of Absence Form - California State University Fullerton Page 7

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PART B: AMOUNT OF LEAVE NEEDED
5.
Will the employee be incapacitated for a single continuous period of time due to his/her medical
condition, including any time for treatment and recovery?
No
Yes
If so, estimate the beginning and ending dates for the period of incapacity:
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced
schedule because of the employee’s medical condition?
No
Yes
If so, are the treatments or the reduced number of hours of work medically necessary?
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:
Estimate the part-time or reduced work schedule the employee needs, if any:
hour(s) per day;
days per week from
through
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her
job functions?
No
Yes
No
Yes
Is it medically necessary for the employee to be absent from work during the flare-ups?
If so, explain:
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:
months(s)
times per
week(s)
Duration:
day(s) per episode
hours or
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDTIONAL ANSWER.

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