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Medical Certification Of Health Care Provider For Employee'S Serious Health Condition Form - Montgomery County Government Page 3

MCPR, 2001

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

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? ___Yes ___No.

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? ___Yes ___No.

If so, are the treatments or the reduced number of hours of work medically necessary?

___Yes ___No.

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? ____Yes ____ No.

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

____ Yes ____ No. If yes, 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

P – 1-3

Medical Certification Of Health Care Provider For Employee'S Serious Health Condition Form - Montgomery County Government Page 3