Form Cfn 552-0755 - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) - Iowa Department Of Administrative Services Page 3
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4PART 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:
From:
______________________
To:
____________________________
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 ADDITIONAL ANSWER.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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CFN 552-0755 10/11
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