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SUE~JTdC'T: FAMILY MEDICAL LEAVE AC'T (~.} ~AG'!r 4 6 , 02 <br />PAGE 13 of 19 <br />Fs'sC}mate the part-time ox' reduced wcaz°k sc17~~riul~ t.}icy <br />~zrnployee needs, i f any: lzaur (s} pex~ day; <br />days pez: week from through ~~~ <br />1. V~'i11 the condition cause episodic flare-ups periodica:l..iy prevent.iny <br />the employee from performing his/1~ez° job functions? ~Na <br />Yes <br />L~; it medically nece.~sary for the emplo}ree to be absent <br />from work during the flazreWu.ps? No Yes If ~~o, <br />- -- <br />ehplain: <br />La:,ed upon the patient's rnedica7 Yiistory and you c~ knowl ed~~E> <br />at the medical condition, estimate tFze frequency of frare <br />ups and the duration of related izzcapac:ir..y that t_}ze patient. <br />rrta}' have over the next 6 months (e.c~, 1. episode evexy t <br />months lasting 1-2 days): <br />irequency: _ _- times per ----week(s)_____month(s) <br />Duration:~__hours oz-~._day(s) per episode <br />ADDITIONAL INf'C7RMA'TIUN: IDI~,N"I'I1'Y (ZU~:STItJN NUM13~:Ft. WTT'H YOUR <br />ADDITIONAL ANSWER. <br />Signai:ure of Health Cale provider Dace <br />