Asu Fmla Certification Of Health Care Provider For Employee'S Pregnancy Page 3
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34. 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)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PART B: AMOUNT OF LEAVE NEEDED
5.
Will the employee be incapacitated and absent from work 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:___________________________________________
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 the job functions?
No
Yes;
Is it medically necessary for the employee to be absent from work during the flare-ups?
No
Yes. Please 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:
__________ time(s)
Every:
__________ week(s)
or
__________ month(s)
Lasting:
__________ hour(s) per episode
or
__________ day(s) per episode
ADDITIONAL INFORMATION
Attach additional sheets as needed. Please include your provider name and the employee’s name on each page
and identify the question number with each of your answers.
_______________________________
__________________________________
____________
Health Care Provider’s Name (Print)
Health Care Provider’s Signature
Date
HEALTH CARE PROVIDER: PLEASE RETURN THIS FORM TO THE ADDRESS AT THE TOP OF PAGE 1
Office of Human Resources | Benefits Design & Management
FMLA Certification of Health Care Provider for Employee’s Pregnancy
Page 3 of 3
Revised: August 2010
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