Fmla Questionnaire Form (Page 5 of 5) in pdf

. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily

No ____ Yes ____

activities?

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) or per _____ month(s)

Duration: _____ hours or ___ day(s) per episode

No ____ Yes ____

Does the patient need care during these flare-ups?

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

___________________________________________________________________________________________

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

__________________________________________________________________________________________

Signature of Health Care Provider and Date

: _______________________________________________________

If submitted, it is mandatory for employers to

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to

respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it

will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If

you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing

this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW,

Washington, DC 20210.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

Page 4 Form WH-380-F Revised May 2015

Fmla Questionnaire Form Page 5