Common use of AMOUNT OF LEAVE NEEDED Clause in Contracts

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: 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 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 Employer name and contact:

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: 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 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 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies. Employer name and contact:

AMOUNT OF LEAVE NEEDED. 5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including 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 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 Employer name and contact:

AMOUNT OF LEAVE NEEDED. 5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including 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 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 Employer name and contact:

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: 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 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 certifications, recertifications, or medical histories of employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies. Employer name and contact: