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 SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical certification issued by the health care provider of the covered family member. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. 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. Limit your responses to the condition for which the patient needs leave. Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page. PART A: MEDICAL FACTS 1. Approximate date condition commenced: Probable duration of condition: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes . If so, dates of admission: Date(s) you treated the patient for condition: Was medication, other than over-the-counter medication, prescribed? No Yes. Will the patient need to have treatment visits at least twice per year due to the condition? No Yes Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? No Yes If so, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? _ No Yes. If so, expected delivery date: 3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

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 SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical certification issued by the health care provider of the covered family member. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§§ 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. SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS 29 U.S.C. §§ 2613, 2614(c)(3). Failure to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully provide a complete and completely, all applicable parts below. 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 sufficient medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” certification may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page. PART A: MEDICAL FACTS 1. Approximate date condition commenced: Probable duration of condition: Was the patient admitted for an overnight stay result in a hospital, hospice, or residential medical care facility? No Yes denial of your FMLA request. If so, dates of admission: Date(s) you treated the patient for condition: Was medication, other than over-the-counter medication, prescribed? No Yes. Will the patient need to have treatment visits at least twice per year due to the condition? No Yes Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? No Yes If so, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? _ No Yes. If so, expected delivery date: 3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):29

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 SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical certification issued by the health care provider of the covered family member. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§§ 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. SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS 29 U.S.C. §§ 2613, 2614(c)(3). Failure to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully provide a complete and completely, all applicable parts below. 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 sufficient medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” certification may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page. PART A: MEDICAL FACTS 1. Approximate date condition commenced: Probable duration of condition: Was the patient admitted for an overnight stay result in a hospital, hospice, or residential medical care facility? No Yes denial of your FMLA request. If so, dates of admission: Date(s) you treated the patient for condition: Was medication, other than over-the-counter medication, prescribed? No Yes. Will the patient need to have treatment visits at least twice per year due to the condition? No Yes Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? No Yes If so, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? _ No Yes. If so, expected delivery date: 3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):29

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. _________________ 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 SECTION I: For Completion by the EMPLOYER episode INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical certification issued by the health care provider of the covered family member. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS § 825.306-825.308. Employers must generally maintain records and documents relating to the EMPLOYEE: Please complete Section II before giving this form to your medical certifications, recertifications, or medical histories of employees’ family member or his/her medical provider. The FMLA permits an employer to require that you submit a timelymembers, complete, and sufficient medical certification to support a request created for FMLA leave to care for a covered family member purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. 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. Limit your responses to the condition for which the patient needs leave. Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page. PART A: MEDICAL FACTS 1. Approximate date condition commenced: Probable duration of condition: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes . If so, dates of admission: Date(s) you treated the patient for condition: Was medication, other than over-the-counter medication, prescribed? No Yes. Will the patient need to have treatment visits at least twice per year due to the condition? No Yes Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist29 C.F.R. § 1630.14(c)(1)? No Yes If so, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? _ No Yes. If so, expected delivery date: 3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):Americans with Disabilities Act applies. Employer name and contact:_______________________________________________________ _____________________________________________________________________________