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SUI3JEC'I': CAMS:L,Y MLUICAL LEAVE ACT (L} PALL 3 t.02 <br />PAGE ].2 OF 19 <br />2. Is the medical condition precJnancy? No Yes If so, <br />expected delivery date: <br />3. Use tt.cs ir;for.-rnation provided by the employer in Section I to an:_;wer <br />this question. Zf the emplayer• fails to provide a list of the <br />employee's essential functions or a job description, answer tlie:te <br />c}uestiarYS based upon the employee's. own de::,cription of his,lher job <br />f unct: i ons . <br />Is the employee unable to perfarm any of Iris/}~ez- job <br />functions due to the condition? Igo Y<~s <br />if so, <br />jJ C' r ~ b Y'rrl : <br />~ident,ify the job funct~a.ons the employee is unable to <br />~. Describe other relevant. medical. facts, if any, related to tht <br />condition faze w}t.ch the empl.ayee seeks leave (uch medical facts <br />may include symptams, diagnosis, ar any regimen of contiruain3 <br />treatment such as the use of spec:kalized equipment? <br />PART B: AMOi.TT7T' OF LEAVE NLEDLll: <br />5. Will t}re employee be incapacitated for a si.rYgle continuous periad <br />of time due to his/her medical. candztiarz, including arty t.iine fr.>r <br />ti'eatmer~t and recovery? No Yes <br />Sf sa, rstirnate the beginning and er3diny datr..s for th+~ <br />period of incapacity: <br />6. Will. the emplayee need to attend follaw-up treatment appaintments <br />or wcark part time ox` an a reduced schedule becausea of thr~ <br />nmplo}gee's medical canditi.on? No Yes <br />Sf sa, are the treatments or thrr reduced number of hours of <br />work rnc~dcally necessax'y? Na Yes <br />Estimate treatment schedule, if any, includir;g tyre dates of <br />arty scheduled appoi~ntmrrnts and the C.imc rrqu.ired fox• ~~ac}~ <br />appoi:rttrnent, ancltzd:ing any .recovery period: <br />