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Medical Certification Of Health Care Provider For Employee'S Serious Health Condition Form - Montgomery County Government Page 2

MCPR, 2001

APPENDIX P-1, FMLA FORM – EMPLOYEE SERIOUS HEALTH CONDITION

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?

___Yes ___No. If yes, 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? ___Yes ___ No.

Was medication, other than over-the-counter medication, prescribed? ___Yes ___No.

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical

therapist)? ____Yes ___No. If so, state the nature of such treatments and expected duration of treatment:

_____________________________________________________________________________________

2. Is the medical condition pregnancy? ___Yes ___No. If yes, expected delivery date:__________________

3. Use the information provided in Section I to answer this question.

Is the employee unable to perform any of his/her job functions due to the condition: ____ Yes ____ No.

If 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 regimen of continuing treatment such as the

use of specialized equipment):

_____________________________________________________________________________________

______________________________________________________________________________

P – 1-2

Medical Certification Of Health Care Provider For Employee'S Serious Health Condition Form - Montgomery County Government Page 2