NALC FMLA Forms - branch 38

NALC Form 4 - Family and Medical Leave Act of 1993Health Care Provider: Please Complete this Form Using Extra Sheets if Needed, and Return to EmployeeMedical Certification—Family Member’s Serious Health ConditionEmployee: Return the completed form to the appropriate PostalService Supervisor, and keep a copy for your own records.1. Patient's name:Employee Name (Print)Relationship to employee: ” Child ” Spouse ” Parent2. Description of serious health condition: The back (p. 2) of this form describes what is meant by a “serious health1condition” under the Family and Medical Leave Act. 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 ” None of these3. Medical facts: Please describe briefly the medical facts which fit the category checked above, without including a specificdiagnosis or prognosis.4. Duration of condition and incapacitya. Date the condition began: Probable duration of the condition:2Probable duration of the patient's present incapacity (if different):b. If the condition is a chronic condition (condition #4) or pregnancy(#3), state whether the patient is presently incapacitatedand the likely duration and frequency of episodes of incapacity:5. If additional treatments will be required for the condition, please describe: the nature of such additional treatments orcontinuing regimen of treatment under your supervision (e.g., prescription drugs, physical therapy requiring special equipment); theprobable number of such treatments; the length of the employee’s required absence for the treatments; and the actual or estimateddates of the treatments, if known.6. Need for employee's carea. Does the patient require assistance for basic medical, hygiene, nutritional needs, safetyor transportation?” Yes ” Nob. If no, would the employee's presence to provide psychological comfort be beneficialto the patient or assist in the patient's recovery?” Yes ” Noc. Will it be necessary for the employee to take time off work intermittently or to work ona less than full schedule as a result of the patient's condition and/or treatments?” Yes ” NoIf yes, give the probable duration:Health Care Provider SignatureAddressPhoneDateOctober, 1995 NALC FMLA Form 4 (Page 1 of 2)