WH 380E Certification of Health Care Provider No 4208

PART A: MEDICAL FACTS1. Appropriate 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?Was medication, other than over-the-counter medication, prescribed?Was the patient referred to other health care provider(s) for evaluation or treatment (e.g.,physical therapist)?□ No □ Yes□ No □ Yes□ No □ YesIf so, state the nature of such treatments and expected duration of treatment: _______________________________________________________________________________________________________________________________________2. Page 4 describes what is meant by a “serious health condition” under both the FMLA and CFRA. Does the employee’scondition qualify as one of the types of health conditions described?□ No □ YesIf yes, which type of serious health condition listed on page 4 applies: □ 1 □ 2 □ 3 □ 4 □ 5 □ 6For FMLA purposes only:If the employee’s serious health condition is type 2 (as defined on page 4), did the employee visit a health care providerwithin 7 days of his/her first day of incapacity?□ No □ Yes3. Is the medical condition pregnancy? □ No □ YesIf so, expected delivery date: _____________________________4. Use the information provided by the employer in Section I to answer this question. If a list of the employee’s essentialfunctions or a job description is not attached, please answer these questions based upon the employee’s own description ofhis/her job functions.□ No □ YesIs the employee unable to perform any of his/her job functions due to the condition:If so, identify the job functions the employee is unable to perform.___________________________________________________________________________________________________5. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medicalfacts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Page 2 CONTINUED ON NEXT PAGE Form WH-380-E Revised January 2009#4208 RCSD/Personnel 10/2009