Employer S Response to Employee S Request for Or Employer S

Employer’s Response to Employee’s Request for or Employer’s Designation of Family or Medical Leave

Family and Medical Leave Act of 1993

SUBJECT: Request for or designation of Family/Medical Leave (FMLA)

On __,  you provided notice, or  your employer became aware of your need to take family/medical leave due to:

 the birth of your child or the placement of a child with you for adoption or foster care;

 a serious health condition that makes you unable to perform at least one of the essential functions of your job;

 a serious health condition affecting your  spouse,  child,  parent, for which you need to provide care;

 because of a qualifying exigency arising out of the fact that your  spouse  son or daughter  parent who is on active duty or call to active duty status in support of a deployment to a foreign country.

 because you are the  spouse  son or daughter  parent  next of kin of a covered service member with a serious injury or illness. You have the right under FMLA for up to 26 weeks of unpaid leave to care for a covered service member with a serious injury or illness that occurred any time during the 5 years preceding the date of treatment. This 12 month period commences ___/___/___.

This notice is to inform you that:

You are  eligible  not eligible for leave under the FMLA.

If it has been determined that you are not eligible for FMLA leave due to:

 You have not met the FMLA’s 12 months length of service requirement. As of the first date of requested leave, you will have worked approx. 4 months towards this requirement.  You have not met the FMLA’s 1,250 hours worked requirement  You do not work and/or report to a site with 50 employees within 75 miles.

 Notice was provided or  your employer designated, that this leave will begin on _ and that you expect leave to continue until on or about (a) ______or  that your leave may need to be taken on an intermittent basis. Be advised that you must adhere to the daily attendance reporting policy,

1 failure to report absences as directed in the attendance policy could lead to termination of employment. q If the established/requested end (see “a” above) of your FMLA qualified leave requires an extension (not to exceed 12 weeks total leave) you must contact your supervisor within 2 days of learning that your FMLA leave will need to be readjusted/extended, failure to do so may create a violation of attendance policy..

Continuous leave from ___ to _ = 12 weeks, if you do not qualify for intermittent leave you must return to full duty status on or before (b) ___.

Failure to return to full duty status by the day noted may be considered as a voluntary quit of your employment, and will end your employment relationship and/or your eligibility for benefits, please make note of the above referenced dates (a) or (b) above, you will receive no further notice of your need to return to full duty status on or before the day noted.

Except as explained below, you have a right under the FMLA to take up to 12 weeks of unpaid leave in a 12-month period for the reasons listed above. The 12 month period of time is measured forward from the date of your first FMLA leave usage. Your health benefits will be maintained during any period of unpaid leave under the same conditions as if you continued to work, and you must be restored to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from FMLA protected leave. If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious health condition that would entitle you to FMLA leave (not to exceed a total of 12 weeks within a one year period of time) (2) the continuation, recurrence, or onset of a covered service member’s serious injury or illness which would entitle you to FMLA leave (3) other qualifying circumstances beyond your control, for a minimum of 30 days, you may be required to make reimbursement for health insurance premiums paid on your behalf during your FMLA leave.

 your medical condition is the result of an “on the job injury” and thus covered by Worker’s Compensation, the leave time taken for the on the job injury and FMLA leave will run concurrently.

The requested leave x will  will not be counted against your annual FMLA leave entitlement.

You  will  will not be required to furnish medical certification of a serious health condition. If required, you must furnish certification by ______(date must be at least 15 days after you are notified of this requirement), or we may delay the start of your leave until the certification is submitted, failure to provide medical certification can delay the beginning of your leave and have a negative effect on your continued employment.

You may choose to substitute accrued paid leave for unpaid FMLA leave. We  will  will not require that you substitute accrued paid leave for unpaid FMLA leave. If paid leave will be used, the following conditions will apply : Any accrued vacation or personal/sick time that you have, will first be applied to your leave. For example, if you have one week of paid vacation available the first week of your leave will be counted as paid vacation in conjunction with FMLA leave and you would then have up to 11 weeks of unpaid leave available. The same applies for any accrued paid sick/personal time. If you have any questions about us applying paid vacation and sick/personal leave to your FMLA leave contact the HR Department.

2 If you normally pay a portion of the premiums for your health insurance, these payments will continue to be your responsibility during the period of FMLA leave. Discuss arrangements for the paying of your share of your health, dental and vision premium with your supervisor or manager, it is required that you will make premium payments as follows (premiums due must be paid by the 10th of the month in order to be covered with uninterrupted insurance coverage.): if you have any questions concerning premiums please discuss it with your on- site Supervisor or HR personnel.

You will have a 30-day grace period in which to make payment. You will notifies 15 days before the grace period ends if your payment has not been made. If your payment has not been made when the grace period ends, your group health, dental or vision insurance may be canceled, or, at our option, we may pay your share of the premiums during the FMLA leave and recover those payments from you when you return to work.

If you are currently on the Company sponsored health plan: Your share of the premiums for your health, dental and vision insurance x will  will not will be paid while you are on leave.

The same  will x will not be done for other benefits (e.g., life insurance, disability insurance, etc.) while you are on FMLA leave. If premiums are paid for health insurance or other benefits, when you return from leave you x will  will not be expected to make reimbursement for these costs.

You  will  will not be required to present a fitness-for-duty (ability to perform the essential elements of your position) certificate before being restored to employment. If such a certificate is required but not received, your return to work may be delayed until the certificate is provided.

You  are x are not a “key employee” as described in §825.218 of the FMLA regulations. If you are a “key employee,” restoration to employment may be denied at the end of your FMLA leave because such restoration will cause substantial and grievous economic injury to us as described in §825.218.

It has been determined that restoring you to employment at the end of your FMLA leave  will x will not cause substantial and grievous economic injury. (substantial and grievous economic harm described §825.279 of the FMLA regulations)

While on leave, you x will  will not be required to furnish us with periodic reports  every Monday morning, to your supervisor  every other Monday morning, to your supervisor, of your status and intent to return to work (see §825.309 of the FMLA regulations). If the circumstances of your leave change and you are able to return to work earlier than the date indicated on page one of this response, you x will  will not be required to notify us at least two workdays before the date you intend to report for work.

Failure to return to work when FMLA leave has been exhausted will result in an end to your employment. It is your responsibility to maintain contact with your employer in order for the employer to know whether or not a replacement must be hired in the event you do not plan on returning to work. Failure to report to work at the conclusion of your authorized leave will be considered a voluntary quit. Your employer will not notify you further when your leave period is due to end, it is your responsibility to return to work on or before the end date noted on page 2 ((a) or (b)) or to make contact with your employer to explain why you cannot return to work as scheduled, contacting your employer does not qualify you for or obligate the employer to provide additional FMLA qualified leave.

3 You x will  will not be required to furnish recertification relating to a serious health condition. (Explain below, if necessary, including the interval between certifications as provided in §825.308 of the FMLA regulations.)

You will be required to provide certification or recertification (if certification was originally required), or if your original leave was for child birth and you subsequently request additional leave for a reason other than child birth, or if your leave extends beyond the time frame that was originally requested or designated. A request for additional leave does not obligate your employer to extend your qualified leave period beyond 12 weeks, nor does this request for additional leave time give you any other rights under FMLA.

Leave for the birth or adoption of a child must be taken in one block of time, i.e. you may not take 6 weeks of leave – return to work for two weeks – and take an additional 6 weeks for “bonding”. Any leave taken for the birth or adoption of a child after the initial leave period will require a physicians certification before the leave is approved as qualified FMLA leave.

If your 12 week entitlement has been exhausted, and you return to work on a part-time basis (less than 30 hrs per week), it is certain that you will not continue to qualify for health care coverage benefits

If you have any questions or concerns please contact Adrienne Wall -Human Resources Advisor at A-Plus Benefits, Inc. 801.443.1090 or 1.800.748.5102

FMLA Eligibility Requirements

ELIGIBLE EMPLOYEES

An employee who has been employed by the company for 12 months / 52 weeks as of the date the leave commences. During the proceeding 12 months / 52 weeks the employee

4 must have worked a minimum of 1250 hours and the Employer has at least 50 employees (during 20 weeks of the previous calendar year or 20 weeks during the current calendar year) within 75 miles of the worksite. Your worksite employer is your Primary Employer, A Plus Benefits, Inc. is your Secondary Employer.

Requests for leave before eligibility:

In the event the employee notifies of the need for leave before the employee has met the eligibility requirements, the company may wait to confirm eligibility until the employee has met the stated requirements.

ELIGIBLE LEAVES

1. For the birth of a son or daughter, and to care for the newborn child.

2. For placement with the employee of a son or daughter for adoption or foster care.

3. To care for the employee's spouse, son, daughter, or parent, with a serious health condition.

4. Because of a serious health condition that makes the employee unable to perform the functions of the employee's job.

5. Because of a qualifying exigency arising out of the fact that an employee, or an employee’s spouse, son, daughter, or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves. or, because the employee is a spouse, son, daughter, or parent, or next of kin of a covered service member with a serious injury or illness.

Miscellaneous: Medical certification may be required for serious health conditions. Certain leaves may be required before the actual event, e.g., leaves for the birth of a child or for placement for adoption or foster care. No maximum age limits applies to children who are the subject of adoptions or foster care placements.

LEAVE ENTITLEMENT - Medical Up to 12 weeks of FMLA leave in any 12-month period.

12 -month period: The 12-month period of time is measured forward from the time that leave commences. Leave for birth or placement for adoption or foster care must end within 12 months after the birth or placement.

5 Husband and wife: In the event that both the husband and wife are employed by the company, only a total of 12 weeks combined leave may be taken for birth (or subsequent care), placement for adoption or foster care ( or subsequent care), or to care for a parent with a serious health problem.

LEAVE ENTITLEMENT – MILITARY

Exigency Leave : Up to 12 weeks of unpaid leave during a 12 month period for exigent leave benefits for family members of covered military personnel.

Caregiver leave: Up to 26 weeks of unpaid leave during a 12 month period to care for a family member (spouse, son, daughter parent or next of kin) who is injured while serving on active military duty. Caregiver leave provision include veterans who are undergoing medical treatment, recuperation or therapy for serious injury or illness that occurred any time during the five years preceding the date of treatment.

12 -month period: The 12-month period of time is measured forward from the time that leave commences.

INTERMITTENT OR REDUCED LEAVE SCHEDULE Leave may be taken on an intermittent or reduced leave schedule in the following situation :

1. When "medically necessary", if due to a serious health condition of the employee or family member. Intermittent leave may be either limited (e.g., for medical appointments) or lengthy (e.g., for chemotherapy).

Affect on leave entitlement : Only the actual time taken as FMLA leave is charged against an employee's entitlement. For part-time employees and those working variable hours, the FMLA leave entitlement is calculated on a pro-rata or proportional basis. For example : if a 30 -hour-per-week employee is reduced to 20 hours per week the 10 hours of FMLA leave equals one-third of a week of FMLA leave each week, if an employee's work week schedule varies, the average weekly hours worked during the 12 weeks prior to FMLA leave will be considered the "normal" work week.

Temporary transfers : An employee may need to be temporarily transferred to another position to better accommodate the recurring periods of leave. The alternate position must have equivalent pay and benefits.

Requirement to report unscheduled absences. Employees must adhere to the attendance reporting policy while on intermittent leave. An employee must notify the proper supervisor when the employee must miss work due to an unscheduled need for intermittent leave. Failure to follow established policy for calling out “sick” may lead to termination of employment.

6 PAID / UNPAID LEAVE Leave need not be paid. However, paid vacation or personal leave may be substituted without limitation, for any FMLA - qualifying purpose.

Family / medical / sick leave : An employee or employer may unilaterally elect to use paid vacation if FMLA leave is due to birth, placement for adoption or foster care, or to care for the serious health condition of a family member.

Miscellaneous : FMLA leave entitlement is not reduced by paid leaves which are non-qualifying and is not expanded after childbirth simply because multiple purposes for the leave could each independently support FMLA leave.

DESIGNATION OF FMLA LEAVE (OR NOT) The company designates leave (or portions) as FMLA – whether the leave is qualifying or not is based on information obtained from the employee.

Notification / timing : Once leave is designated as FMLA leave, the employee will be notified immediately. If the company requires paid vacation be substituted for unpaid leave, or that leave must be counted as FMLA leave, the designation must be made at the time the employee requests or gives notice of the leave (or as soon thereafter as it is determined that the leave is FMLA qualified). This designation must be made before the leave starts, unless sufficient information is unavailable, leave may also be retroactively redesignated.

EMPLOYEE BENEFITS DURING LEAVE The employee's group health plan coverage must continue on the same conditions as if continuously employed and the same benefits must be maintained.

Premium payments : If the leave is paid, employees pay premiums in the manner customarily used (payroll deduction). If the leave is unpaid the insurance premium is due at the same time as if by payroll deduction, or by prepayment in advance.

Late payments : If premium payments are more than 30 days late, the company's obligation to maintain health insurance coverage ceases. If coverage lapses for late payment, upon employment reinstatement, equivalent coverage / benefits / terms will be restored to the employee ( without any qualification requirements, including a preexisting condition waiting period, or a wait for the next open enrollment period)

Recovery of premiums : Any premium payments advanced to an employee delinquent in the employees payments will be recovered. If an employee fails to return from unpaid leave after the FMLA leave entitlement has expired, premiums

7 that the company paid for maintaining coverage will be recovered ( for up to the entire leave period), unless the employee does not return due to the following conditions :

1. The continuation, recurrence, or onset of an FMLA qualified serious health condition (medical certification will be required).

2. Other conditions beyond the control of the employee as defined in the "ACT".

Recovery is limited to premiums paid during appropriate unpaid periods of leave.

Benefits reinstatement / maintenance : An employee choosing not to retain health coverage during the leave is entitled to reinstate coverage upon returning, on the same terms as before, without any qualifying period. Expect as required by COBRA and for key employees, the obligation to maintain health benefits ceases if and when an employee:

1. Informs the company of the employees intent not to return,

2. Fails to return,

3. Exhausts the employee FMLA leave entitlement.

Plan amendments : The employee is entitled to any new or changed plan benefits (including notices) to the same extent as if not on leave.

"Key" Employees : A "key" employee given notice that "substantial grievous economic injury" would occur if the employee were reinstated, who does not return, is still entitled to group benefits until:

1. The employee advises the company that reinstatement is not desired.

2. FMLA leave entitlement is exhausted.

3. Reinstatement is actually denied.

EMPLOYMENT REINSTATEMENT After FMLA leave, an employee is entitled to the same or equivalent position, with equivalent benefits, pay and other terms and conditions of employment.

Job qualifications : Upon return to work, an employee must be allowed a reasonable opportunity to fulfill all job qualifications. ADA may govern situations in which a physical or mental condition impacts abilities.

8 Pay : An employee must be granted any unconditional pay increase which occurred during the leave period.

Benefits : Unless otherwise elected by the employee, benefits must be resumed in the same manner and at the same levels. FMLA leave is continued service for purposes of vesting or eligibility to participate in a pension or other retirement plan, however other benefits that accrue with time worked (vacation, sick leave, etc.) will not accrue during FMLA leave.

Position : An equivalent position must include the same working conditions, privileges, perks and status, and must involve the same or substantially similar duties and responsibilities, requiring substantially equivalent skill, effort, responsibility and authority.

Limitations : An employee has no greater rights than if leave had not been taken. An employee hired for a specific term or project need not be restored if the term or project is over and the employee would not otherwise have continued in employment. Restoration may be denied to certain "key" employees as well as to certain employees who fail to provide fitness for duty certificate.

KEY EMPLOYEES A salaried employee, is a FMLA eligible employee who is among the highest 10% (but not more than 10%) of all employees. Earnings include wages, premium pay, incentive pay, and bonuses, but do not include incentives to be valued at some future date, (e.g., stock options), benefits, or perks.

Denial of employment reinstatement : Denial of employment reinstatement to a key employee is a function of a determination that restoration (not the absence) would cause "substantial and grievous economic injury" to the company's operations.

Determinations and notices : If the company believes reinstatement may be denied, an employee must be given written notice of the employee's Key employee status, at the time FMLA leave is requested or commences.

EMPLOYEE NOTICE TO THE COMPANY

If need for leave is foreseeable : At least 30 days advance notice must be given if the need is for birth, placement for adoption or foster care, or planned medical treatment for a serious health condition. If 30 days notice is not practical, notice must be given as soon as both possible and practical under the circumstances (normally that would mean at least verbal notice to the human resource department within 1 or 2 business days after the employee knows of the need). Failure to meet requirements : Employees failing without reasonable excuse to give the required 30 days notice may be denied FMLA leave until at least

9 30 days notice is given. It must be clear, however, that,

1. The employee has actual notice of the FMLA requirements.

2. The need for leave and the approximate date leave would be taken must have been clearly foreseeable to the employee 30 days in advance.

If need for leave (or timing) is not foreseeable : The notice should be given as soon as practicable under the circumstances, normally within no more than 1 or 2 working days of learning of the need for the leave. It should be provided either in person, or by phone, telegraph, fax machine or other electronic means. If the employee is unable to do so personally, it may be provided by the employee's representative, spouse, family member, etc..

MEDICAL CERTIFICATION

Company Requests : While the notice to employees of overall medical certification requirements must be written, the actual request for certification may be verbal. Along with the request for certification, the employee may be advised of the anticipated consequences of failure to provide adequate certification. Reasonable opportunity to present certification will be provided.

Frequency : Certification may be requested whenever reasonably necessary; recertification may be requested at any reasonable interval, but not more often than every 30 days, unless:

1. A leave extension is requested.

2. Circumstances have significantly changed since the original certification.

3. The company has good reason to doubt the continuing validity of the certification. Certification may also be required when an employee alleges inability to return to work due to a serious health condition (which impacts the company's ability to recover its share if benefit premiums made on the employee's behalf during unpaid FMLA leave).

Due date : Unless not practicable under the circumstances (despite diligent good faith efforts), an employee must provide medical certification within the time frame requested by the company, or within 15 calendar days, whichever is later.

Employee failure to meet requirements : If leave was foreseeable, leave may be

10 denied until certification is provided. If not foreseeable, continuation of leave may be denied if an employee fails to provide certification within a reasonable time, considering the circumstances. Reinstatement at the end of leave may be denied until applicable certification requirements are met.

Return-to-work certifications (fitness-for-duty reports)

Conditions : The company requires that all employees who take leave for their own serious health conditions provide medical certification that the employee is able to return to work.

Notices to employees : An employee from whom such certification will be required must also be given specific notice of the requirements at the time leave is requested or immediately after leave commences.

Miscellaneous : Employment restoration will be denied until employee provides such certification. Failure to provide certification by the final return to duty date may result in termination if the employment relationship.

Failure to return to full duty status when leave authorization expires:

Failure to return to work at the end of FMLA authorized leave will be considered as the employees voluntary resignation from employment.

WORKER’S COMPENSATION LEAVE

When an employee is injured on the job and the injury requires that the employee must be on a medical leave, the medical leave time will be considered as qualifying for leave under the rules of FMLA.

When an employee is injured on the job and the medical leave is considered Worker’s Compensation leave, and if that leave time is also considered to be FMLA leave, the employee is eligible for benefits related to health insurance that the employee could not otherwise retain.

A Worker’s Compensation medical leave will be considered to be an FMLA qualified leave.

Worker’s Compensation medical leave and FMLA qualified leave will run concurrently.

OTHER EMPLOYMENT WHILE ON LEAVE

11 Employees are prohibited from taking other employment while on any approved leave of absence, including Family and Medical Leave Act designated leave.

Any employee who begins other employment whether full-time, part-time, or self employment, while on any approved leave, will be considered to have voluntarily resigned from their employment on the day that the other employment begins.

WORK AT HOME WHILE ON LEAVE

Exempt and non-exempt employees are not authorized to work from home while on leave. Employees should leave company owned lap top computers and cell phones (Blackberries, iphones, etc.) at the worksite while on FMLA qualified leave. Checking e-mail, voice mail, etc. while on FMLA qualified leave is not permitted.

While on FMLA qualified leave employees are not allowed to perform any business functions while at home without the express written consent of their direct executive supervisor.

Attention Employee: This form (pages 13-16) must be completed by your treating Physician and returned to Adrienne Wall, A-Plus Benefits, Inc. PO Box 849 Pleasant Grove, UT 84042, and be postmarked, on or before __, failure to return this Physician’s Certification, as required, may result in a denial of your leave being designated as qualified FMLA leave, your absences may then be considered to be without authorization and may lead to your discharge. It is your sole responsibility to ensure that this form has been returned on time. This is the only notification you will receive of your responsibility to return this certification on time. After the above deadline date lapses, you will not receive additional reminders that this certification has not been received, this is your only and final notice.

Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act)

12 EMPLOYEE:

INSTRUCTIONS to the EMPLOYEE: Please complete this section before giving this form to your 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 due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).

Employee's Serious Health Condition – The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information” as defined by GINA includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Family Member’s Serious Health Condition – The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information” as defined by GINA includes the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Please provide medical history information regarding your patient only to the extent necessary to fully respond to all relevant items below.

Your name: ______First Middle Last

HEALTH CARE PROVIDER:

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. 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 employee is seeking leave. Please be sure to sign the form on the last page.

Provider’s name and business address______

13 Type of practice / Medical specialty: ______

Telephone: (______)______Fax:(______)______

PART A: MEDICAL FACTS

1. Approximate date condition commenced: ______

Probable duration of condition: ______

Mark below as applicable:

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: ______

Will the patient need to have treatment visits at least twice per year due to the condition? ___No ___ Yes.

Was medication, other than over-the-counter medication, prescribed? ___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. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s own description of his/her job functions.

Is the employee unable to perform any of his/her job functions due to the condition: ____ No ____ Yes.

If so, identify the job functions the employee is unable to perform: ______

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

______

14 ______

PART B: 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

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER. ______

______

15 Signature of Health Care Provider Date

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.