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The employee authorizes a licensed health care provider to complete the form and submit it to District 120 Human Resources. The form collects details about the medical condition, hospitalization, treatment dates, expected duration, pregnancy status, essential job function limitations, incapacity periods, and follow-up needs, while instructing providers to avoid genetic information under the Genetic Information Nondiscrimination Act. 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Please answer, fully and completely all applicable parts of this form. Several questions seek a response as to the frequency or duration of a condition, treatment plan, etc. Your answers should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Please be as specific as possible and limit your response to the condition for which the employee is seeking leave. When applicable, circle YES or NO to indicate your response.  \nThe Genetic Information Nondiscrimination Act of 2008 prohibits employers from requesting or requiring genetic information of an 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 this law, includes an individual’s family medical history, 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.  \nTO BE COMPLETED BY THE HEALTH CARE PROVIDER  \nProvider’s Name:    \nProvider’s Business Address:    \nType of Practice/Medical Specialty:    \nTelephone: (  )   Fax: (  )    \nWhen did the medical condition(s) begin?  \nHow long is the condition expected to last? If the condition is permanent, please indicate.  \nWas the patient admitted for an overnight stay in a hospital or residential medical care facility? If yes, what were the dates of admission?  \nWhat were the dates in which you treated the patient for this condition?  \nWill the patient require treatment at least twice per year due to the condition? YES or NO Was medication, other than over-the-counter medication prescribed? YES or NO Was the patient referred to other health care providers for evaluation or treatment? If yes, please state the nature of the treatments and expected duration of treatment.  \nIs the medical condition pregnancy? YES or NO If yes, expected delivery date:   Has the patient provided you with their job description? YES or NO If no, please answer these questions based upon the patient’s own description of their essential job functions.  \nIs the patient unable to perform any of their essential job functions due to the condition? YES or NO If yes, identify the job functions the employee is unable to perform.  \nDescribe other relevant medical facts, if any, related to the condition for which the employee seeks leave.  \nWill the patient be incapacitated for a single continuous period of time due to this condition, including any time for treatment and recovery? YES or NO  \nIf yes, estimate the beginning and ending dates for the period of incapacity:  \nWill the patient require follow-up treatment appointments or work part-time/reduced schedule because of the condition? YES or NO If yes, are the treatments or reduced number of hours worked medically necessary? YES or NO  \nPlease list the estimated treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:  \nEstimated part-time/reduced work schedule the employee needs, if a","cbCaitrOb7qU96D4","https://ap.wps.com/l/cbCaitrOb7qU96D4","pdf",320196,"English","# To be completed by employee\n# Instructions for the Health Care Provider\n# To be completed by the health care provider\n# Submission instructions","[{\"question\":\"What is the purpose of this FMLA application form?\",\"answer\":\"It is used to describe the employee’s medical condition so the employer can determine eligibility for leave under the Family Medical Leave Act.\"},{\"question\":\"What does the employee need to do on the form?\",\"answer\":\"The employee provides authorization for the medical provider(s) to complete the form using information from the patient’s file and to submit it to the District 120 Human Resources Director.\"},{\"question\":\"What information must the health care provider provide?\",\"answer\":\"The provider must enter practice and provider details and answer questions about when the condition began, expected duration, hospitalization and treatment dates, whether the patient requires treatment at least twice per year, job function limitations, incapacity dates, follow-up needs, and episodic flare-ups.\"}]","Family Medical Leave Act (FMLA) Application Form - Employee and Health Care Provider Instructions | PDF",1789840220]