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Family Medical Leave Act (Fmla) And Oregon Family Leave Act (Ofla) Forms Packet, Form Cd 1422 - Employee Medical Status Report Page 5

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s

need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety

or transportation needs, or the provision of physical or psychological care:

4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and

recovery? ___No ___Yes.

If so, estimate the beginning and ending dates for the period of incapacity: _______________________________

During this time, will the patient need care? __ No __ Yes.

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

Estimate the employee’s dates of absence from work:

5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes.

If so, estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for

each appointment, including any recovery period:

__________________________________________________________________________________________

During this time, will the patient need care? __ No __ Yes.

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

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

activities requiring care on an intermittent or reduced schedule basis? ____No ____Yes.

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

Does the patient need care during these flare-ups? ____ No ____ Yes.

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

Signature of Health Care Provider

Date

Please return this form to the patient or FAX to the Department of Corrections Human

Resources FMLA/OFLA at (503) 362-2078.

Family Medical Leave Act (Fmla) And Oregon Family Leave Act (Ofla) Forms Packet, Form Cd 1422 - Employee Medical Status Report Page 5