Free Declaration in Support - District Court of California - California

i •@• Wggase 3:07-cv-03114- Document 48-9 File 09/05/ 3 Page 1 of 2 A
§ @ PERMANENTEe `Ai ----» I 52/y0
VISIT VERIFICATIONIFAMILY LEAVE Health Care Provider Certification AA . . A
, _ _ , _. . - ., , . . Patrent Name »;
iv (This section must be completed and determlnedby treating provider only) ‘ 4 ·· r ~ , . , .
me ABOVE amen reason; _ . |d¢¤*¤*¤¢=¤¤¤ V
El N0, does not have a “Serious Health Condition" (see reverse tor further information) OR I ( _ e>£‘ A
EYES, has a “$erious_ Health Condition", as defined below (check one):_ O A ‘ - ; __
A 1. El Hospitalcare Ll] Chronic condition requiring treatment · ‘ * _r
2. El Absence plus treatment El ls currently incapacitated - ~ - lmr·nlNT AREA ,
3. El Pregnancy El Is not currently incapacitated · ° · E · I ‘ ~ . -· gi
V 5. El Permanent/long-term condition requiring supervision 6. El Multiple treatments (nonrchronic condition) ·
El Has a "Serious Health Condition” and requires a family member to take time oft from work to provide basic medical, personal or safety needs, transportation, or Q
psychological comfort. The probable frequency and duration of this need is ;_
Ellistimated date of Surgery/Procedure/Delivery: ... _ _ . _ i _ V V V _
Cl Diagnosis (Complete on patient request only):
THE ABOVE NAMED PERSON: » V ·
U Was soon at this office on: El Has be glv telephone advice-err; .
A as beeneill and unable to attend work/school/physit>al~-educatiort through
· El States he/she has been ill and unable todattend workischool/p_ltysit;al education.,,?_.. Ethrough A V ~ A · ( V >~
[I cen return to ron autres with N0 RESTRICTIONS err ?A
. A EI Can partlclpate In a modified work; starting and contlrnrlng to ,
V (Pleasenote: lf modified Is Aavallable, thls patient la then unable to work for thla tlme perlod.) ‘ r V . ·A . . ._ · j
El Flestrictionsa_.......... g hours per day r hours per weekA A ’ AA · ‘
BASED ON AN B¥H0UAR DAY EMPLOYEE CAN: · . ,___ _A _ A _ A Q ” A A
stand/walk minute, _ep_ hour total hours lj no restrictions - A ,
sit Z . ...... minutes =- hour total hours [Il no Tgstrigtigng » ‘
V Aurtve minutes per ur A_ V' ‘%Q.%.._.total llQll[$A t V A AVAljAAno restrictions A A A A V
LIFTICARFtY.(Qccasi0nally = up to ‘/s workday. Freq v ntlysupto ?/elyvorkday): · _ ‘ ». ‘ , _ T , » grr ·
0-10 lbs., — . · _ELrt t:at all:. T. occasionally V =-I;] frequently. *I]no restrictions .{ -. _ (
11-25 lbs, _ _ _ [loot . all , [I occasionally T El frequently i Kino restrictions _ - I §l
26-40 lbs. _|:l_notat l_. D occasionally Elerreqoently · El no. restrictions; Q 2;.;
Can Vllft/carry up to .+..........+ lbs. V ` i- A A T ‘
bend V_ _A A __ A _ ljnot at_all_ •s sionally V_ VV[:]freqyentlyVV Vl:]‘npVVrgstrjcttqr;§ A T ’
. squat ‘ Q i I . T El normal: Cl ·~ ¤<>¤¤¤·v "¤. .i 3 2 is
§\ Q kneel __ ( AA - El not at all [joocasi ally |;l‘frequently°AV_ l;lnorestrictiens‘ -· A· it Q if
climb _ Q; i , · l1l*q¤¤,_er‘eli;‘ El melon lZliirigq¤¤nro· t lZlt»¤·r¤s;rl¤l¤¤e r r ¤ l ‘ l
reach above sheolqeg ‘_ ‘ _ l]Fnet‘faiA_alli’·"ffj eeeeslenally_ _ V Eltreqoertuy i » Ijrreireetricrtprts ~ ·’ ~ A i i ( (E
A performgrepetlthreAhaiiit V 2 [3`npt atall l Cl occasionally ‘ El rreqoersnye rréeregmgugm = . ¤ ..V .
l A A$$'$TlV$AQéYl§E$? <éié§{éeéi· ie- ¤r5é=¤.~¤~r¤h¤sl —- ge j `-.. 3 grr Ai... ~ , q. r , ttt_ , 7 ,; .__, g t . .”_i ,‘,‘‘ j ig A; = l
(VV; V :-2;; V , A-,_t;.(V,_ VV _ . ( _ V V _ ·VV_ _VV_ V~ L- :.5; V IV V_:I-VYVVAZVLVVTV VV. Vin"; A VV VV ‘V VVV VV'? VAV V
· · ` i _ _ ` - V _ `Q i,C_,_C; d `___ (
OTHER: A - l
T . ~ A@¤¤marr l 5;;
TREATMENT PLAN: l ‘A A Devo g ff
i ~-»» M5 ¤¤<>i A U Medication effects which could impair performance; . r .¤ ¤¤o¤¤ M I i,.
_ -- . . l Q;}.
U.Physical therapy required. Frequency:· }
- _ atient is industrial, physician signature is REQUIRED. . if-A
S' °"“T°”E W w w ' ‘ A
IU PRINT) · - ' L CATION/AD -· ._ - . P Mlm V _ A I (AF
.. ., fi 4 A E ze t O gg e . E T .a f if
eeoez (REV.2—03) r orsrmeunonr wnm; = cram · pg A Amtnv = PATIENT ' gs

if Case 3:O7—cv—O3114- Document 48-9 Filed O9/O5/2 8 Page:2 of__2 , P— _
. . VISIT VERIFICATION/FAMILY LEAVE Health°.t}are`Provider·Certification.. ‘ . »`»· P —··.=,· y
For the Patient · _ j .__ jj . _ Q. A I _ . _ g Y __ QP ,` _ _ V ._ »
. The visit verification form confirms that you have had a-visit with your healthcare provider..Ad_ditiqnaI .h`é§ilth‘cert`iti¢atioh._ ‘ V . . ‘ `
_ intormation is included on this copy ot the form. This information meets themedical certification requirements, ot the Famihr and- f " F
`Medical Leave 2lct(FMLA) and canine used to document and request family leave from youremployer. Your employer should Y
_ also be able to answer any questions that youlmayrhave about family leave, includingqualifications, and eligibility. L jj
For the Treating Health Care Provider __ _ __ , _ -_ __ ’· _)
ceniiicaiion regarding "Serioiis Health Conditions" must be determined andcompléted by thePtreatirid'lieeIth care proiriderbnly. "‘`` . .
_ -0iqin;_niy,_nnless.co;npl_icaiions_anse, illnesses such as.the.cg.inmon colq,.:tl_u,,upsetstomach;;a.nd%heailaehl§S.titherthanP ·.
migraines do not quality as "Serious Health Conditions". A “SeriousP Health Condition", as defined bythe-FllAL}t;"means'an.illness, " L_ P ,2
»-Y injury, impairmentgcr physical or mental condition-thatfinvolves one otithe-itollowingwti YQ .§.Y.IEEY.; ’‘‘. j
_ _ ____)·-Q-__ ,_,;:,_ ___,_·; __ { ‘ Z; .:P-_j; PA`-. ·»5;z,·;;P; »_`· · - _' _ _ __ Q., T- U ‘ V `
1, Il0§I!ITAL.g:ARE .· l-·;; ., ....., . t..,. -... ,. —* ,.·. . . 4. CHR0NICe.c0tIDlTI0MS.;RE¤UIBING.TREATMENT$—.e·-..»,,,5. r i`
Inpatient care (i.e., an overnight stay) inahospital, , Aehron§e,,co.n_diIlon vvhichz, __ ,;,_ _ _ __ _, _- _, , P .
,_ hospice, `or`residential"rnedical"carefacility, including any “ ` `a.`reqlIi`rés`iierindiE vis'ifs‘for"fiéatin“ént‘Hy’a lIt%5ithTc5re` " ‘
i’*PP‘period·-otincapacity or subsequent treatment in- connection- »- - ~- —» provider;*oPr·’-by-a tiitrse orphysioian’s·¤assistaritP·underee ‘¤-` = ·o"= . i I
mwuumensegueptre e¤eh.t;¤.p¤r¤.ept..ce;e». _ y ...,, , .. . , direetsupervisioneta.heeltl2.eereers2iridsr;-~ -»,,- y »»t.e. rr . — .
. . . . recurring episodes ct a single underlying condition), and - j »
A P A °°"°° °""°a°a°‘”°"“°'°"‘“"""°°°°”$°PF“"l'°iP e may-museepiniaiemnninanannniinnin i eiionni -:>» ‘’‘=
calender days (including any subsequent treatment or 'mca amy 6 a mma: di bet .I _`w
period of incapacity relating to the same condition), that P p i( `g" ‘$ 3 ‘gS* Qmgpshg ‘‘'‘ ” é g,
a'S° '""°"’°$PP ‘ ’i‘`‘i ‘‘‘‘ * ‘P . P PPs.P·r>enMArrErrr/Eoritiefiiiir3l’t:onniriorrs-nEouinmPoP"=P ‘·»—t P _
a. Treatment (iric/udeeeexamfneriape tv determine ite . .sueEnvisiou A.pence-ot—ineanaciiy_wnicn is permanent 52
eerrvve health e¢25;ditir;rr.,ea eeedrrrerr:deeeri¤r’irreiede‘Preerieeerrvereeleidrirei eve housePeneoive.,§ti’l$e‘ZniiiiiiiiiiicminiiyPnaenicei=·mn$i no ·’i’· - ,.._ l gi
or dental exams) two or more times by a healthcare - - P·uyiPuoi¤rho ounrfnonin supervision oe, nut.‘boeP·¤*’i -= --»‘ ~ sie·-r,· V I " Q;
prpvider. by e puree.- pr-phyeieid¤'S eeeieteeeduder-dire¤tP = reeenilno €·- aetlvetrealment uy, aneann ears provider: -=-·—· Pi P P ‘ ‘
, supervision of a healtlrcareiiprovider, Por byiarprovider ofP¤¤P -P -~ »--- Ejmmpiégqngnjdg, Aizhcgmsysl a severe stroke', 0, the ~
health care sewieesii(e.·gz;>P.physical therapistyiinder · -. mmmgi gtg@é$..g,f a dgseasg ...4-<.;
orders of, or on referral by, a health care provider; or , _. l {
lb. Treatment by a health care provider on atleast one 6. MULTIPLE TREATMENTS (IIOII—GHRq_IjI§,§§gtIIlIjIIggI§)_ __o1_ l n
occasion gym v;__=_ _ _;;_ _ ,AV_ L Any perjog qt absence to receive multIpIe“tre’atments"" i
which results in gregirngn{nt-i;ontlnujngEtngatinonl I g____ ,},_‘ ‘ ,(ihcIudinQ_fahy.;period of recovery therefrom) by a health EQ
(includes for ex.@rngjlg,,.a`,coyrse of prescrilitigjrif V ,Q _ g care DEQIQLUQEOTQDY aprovider of health care services undef; , ~, i ?$?
. meoieaiion [eo.,,_an,.an;iniqtie]-‘erznéreingiggiirking QjCQyQ.dtdersg§fgdr.piireferral by. eheelfh care provider. eithertht .,.. Q K . P l i
special equipmerntiyesqlye or al/eviateltlje hea/th ,,;A _,,rigsr¤r;gtrgp,gl;goen alter an accident or rglyer ianjggrykor_tgr_‘___;j P l j
V condition; does not;include_torP.examnlentlgePtaking ef"'., M _§_;¤0¤di§iQn,gh@§FW¤¤|d Ilkelrreetlltltgg rlegidgill,ZQ`;.Q'.`,T_,.I§`jj"T_§,.. Q iii
overethe-counter medications such as aspirin, , I Incapacity ot .more ··~i P ···- a TIIihiSf3Ti7iIT8$§'“0T'$8lI?8$}"0T'bEd`f8$l`;`dI’iIlkiHU`"Uid$, i·-· ·· --·~ P P »-·- P Intrre~e¤s•nee#ef*iii6illérllilriteivefrillemdrtiieiilhiiiit. l
~~»-- .exercisee.and.othersimilar.activities.that.can..beinitJated.. L .... 3S.£8|'\08[...(£hBm0th&IZDy,ITZGIKIIDTL.£IC.)o.$B,\£BIlB:3F[h{t¥lS%¥%zz’£‘?¢f; . " I
__ .,.., ix lingua vial;.rqa..nea1tn.eere_izreyiderzpriderlite. - . .(PhEl9al]DEF§Q¥1;.¥l9DEY,‘9l§€?$F.l‘PlE[¥$*$)v · l” ·i
supervision ofthe health care provider. . ` ` M '“`'` 1 " Q — {
.. -3; FBEEMNQY . - . P -.».- . i PPP:
" Any period of incabacity dueto preoriancy, orfor ` V "``L " ” ` `I ”`'` ‘ ’ ‘ l T5
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Case 3:07-cv-03114-SI

Document 48-9

Filed 09/05/2008

Page 1 of 2

Case 3:07-cv-03114-SI

Document 48-9

Filed 09/05/2008

Page 2 of 2