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Family Member’s Serious Health Condition

Family and Medical Leave Act of 1993 (FMLA)

Employee’s name (Print):_____________________________________________________________

1. Patient’s name:__________________________________________________________________

Relationship to employee:       Child______               Spouse______             Parent_______

2. Description of serious health condition (see Definition of “Serious Health Condition” form):  Does the patient’s condition qualify under any of the categories described?  If so, please check the applicable category:

1__   2__   3__   4__   5__   6__

 

3. Medical facts:  Please describe briefly the medical facts that fit the category checked above, without including a specific diagnosis or prognosis:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

4. Duration of condition and incapacity:

a.  Date the condition began:___________________________________________________________

                  Probable duration of the condition:___________________________________________

      Probable duration of the patient’s present incapacity (if different):____________________________________________

b.  If the condition is pregnancy (condition #3) or a chronic condition (condition #4), state whether the patient is presently incapacitated and what the likely duration and frequency of episodes of incapacity might be.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

5.  If additional treatments will be required for the condition, please describe the nature of such additional treatment under your supervision (e.g., prescription drugs, physical therapy requiring special equipment), the probable number of such treatments, and the actual or estimated dates of the treatment, if known.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

6. Need for employee’s care:

• Does the patient require assistance for basic medical, hygiene, nutritional needs or for transportation?Yes___No__
• If no, would the employee’s presence provide beneficial psychological comfort that would assist in the patient’s recovery?Yes___No___
• Will it be necessary for the employee to take time off, work intermittently, or work on a less than full schedule, as a result of the patient’s condition and /or treatments? Yes___No___

If yes, give the probable duration:_____________________________________________________________

Healthcare Provider Signature and Date:_______________________________________________________

Address:______________________________________________________________

Phone:________________________________________________________________