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Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 3

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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?

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(~,

1 episode every 3 months lasting 1-2 days):

Frequency

: _ _ times per_ week(s) _ _ _ _ month(s)

Duration: _ _ hours or_ day(s) per episode

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Form WH-380-E Revised January2009

Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 3