Fmla Questionnaire Form (Page 4 of 5) in pdf

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that

your patient’s need for care by the employee seeking leave may include assistance with basic

medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or

psychological care:

. Will the patient be incapacitated for a single continuous period of time, including any time for

No ____ Yes ____

treatment and recovery?

Estimate the beginning and ending dates for the period of incapacity:__________________________

No ____ Yes ____

During this time, will the patient need care?

. (If yes, then also answer yes to

question 6 and provide an estimate of the amount of care that will be needed)

Explain the care needed by the patient and why such care is medically necessary: ________________

_________________________________________________________________________________

5. Will the patient require follow-up treatments, including any time for recovery?

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: _________________

___________________________________________________________________________

Explain the care needed by the patient, and why such care is medically necessary:

_________________________________________________________________________________

. Will the patient require care on an intermittent or reduced schedule basis, including any time for

No ____ Yes ____

recovery?

Estimate the hours the patient needs care on an intermittent basis, if any:

________ hour(s) per day; ________ days per week from _______________through_______________

Explain the care needed by the patient, and why such care is medically necessary:

_________________________________________________________________________________

Page 3 CONTINUED

ON NEXT PAGE

Form WH-380-F

Revised May 2015

Fmla Questionnaire Form Page 4