Norristown Area School District Family & Medical Leave Forms Kit (Page 7 of 13) in pdf

PART 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:

_____No _____Yes. Is so, dates of admission:

___________________________________________________________________________________________

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)?

_____No _____Yes. If so, state the nature of such treatments and expected duration of treatment:

___________________________________________________________________________________________

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.

Is 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 regiment of continuing treatment such as the use of specialized equipment):

___________________________________________________________________________________________

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FormWH-380-E Revised January 2009

Norristown Area School District Family & Medical Leave Forms Kit Page 7