Norristown Area School District Family & Medical Leave Forms Kit (Page 8 of 13) in pdf

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_____.

Is it medically necessary for the employee to be absent from work during the flare ups?

_____No Yes_____. 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: ______times per ______week(s) ______month(s)

Duration: ______hours or ______day(s) per episode

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

_______________________________________________________________________________________________

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FormWH-380-E Revised January 2009

Norristown Area School District Family & Medical Leave Forms Kit Page 8