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:
AMOUNT OF LEAVE NEEDED. Please estimate the beginning and ending dates for the period of incapacity:
AMOUNT OF LEAVE NEEDED. For the medical condition(s) checked in Part A, complete all that apply. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage.
AMOUNT OF LEAVE NEEDED. 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: _________________________ 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 ___________ 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 YOUR ADDITIONAL ANSWER: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ __________...
