Free Declaration in Support - District Court of California - California


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Date: September 4, 2008
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State: California
Category: District Court of California
Author: unknown
Word Count: 1,294 Words, 8,179 Characters
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Case 3:07-cv-03114-Sl Document 48-14 Filed O9/O5/2008 Page 1 of 2
• .
§(f)é i PERMANENl'Eo D4 yp 5d /6442%/7 @
VISIT VERIFICATION/FAMILY LEAVE Health Care Provider Certification . /
D _ _ _ Pattent Name
(This section must be completed and determined by treating provider only) _ _ _
me ABOVE NAMED reason; 'd°¤*l*l°¤*l¤¤
' El NO, does not have a “Serious Health Condition" (see reverse for further information) OR ‘ - _
EYES, has a “Serious Health Condition”, as defined below (check one): O 9 gp gé
1. Cl Hospital care 4. El Chronic condition requiring treatment
, 2. [I Absence plus treatment E] ls currently incapacitated IMPRINT AREA
· 3. El Pregnancy E] I: not currently incapacitated
5. I] Permanerrt/long-term condition requiring supervision 6. E] Multiple treatments (non-chronic condition)
I] Has a “Serious Health Condition" and requires a family member to take time off from work to provide basic medical, personal or safety needs, transportation, or
psychological comfort. The probable frequency and duration of this need is
D Estimated date of Surgery! Procedure! Delivery: ;_.DD _

Diag n ws (c m e °" Daum '°q“°St my):
TH ABOVE NAMED PERSON: V
Was seen at this office on: / Z Oé El Has been g' n telepho advice on: V
Has been lll and unable to attend work/school/physical education / Z; D6 through 5 .
El States he/she has been ill and unable to attend work/school/physical educatio ;.;.DD_____ through
El Can retum to full dutlea with NO RESTRICTIONS on OR
, · I;] Can partlclpate In a modlfled work program starting and contlnulng to .._.._.DD_;DD____
(Please note: lf modlfled work ls not available, this patient Ie then unable to work for this tlme perlod.)
El Restrictions: ....._...DD;D__ hours per day ..jD.__D_D_ hours per week
BASED ON AN 8·HOUl=t DAY EMPLOYEE CAN:
stand/walk .;....__..D_ minutes per hour .._;DD.DD___D total hours I:] no restrictions
sit _ _.i minutes per hour ._...._.DD_ total hours Cl no restrictions
drive _....1...._ minutes per hour . _.;__ total hours El no restrictions
LIF'I'/CARRY (Occasionally = up to ’/» workday. Frequently = up to 2/e workday):
O-10 lbs. El not at all El occasionally El frequently El no restrictions
11-25 lbs. El not at all El occasionally El frequently El no restrictions
26-40 lbs. El not at all El occasionally El frequently El no restrictions
Can Iltt/carry upto ...;_;_ lbs.
EMPLOYEE IS ABLE TO:
bend El not at all El occasionally El frequently El no restrictions
squat El not at all El occasionally El frequently El no restrictions
D kneel El not at all El occasionally El frequently El no restrictions
climb El not at all El occasionally El frequently El no restrictions
reach above shoulders El not at all El occasionally El frequently El no restrictions
perform repetitive hand motions El not at all El occasionally El frequently El no restrictions
ASSISTIVE DEVICES? (e.g., cast, brace, crutches)
RESTRICTIONS;


OTHER:
TREATMENT PLAN: D D D D e.,. D DD DDD D D D DDDD DDDD D D DDD DD D DD D DD DDD_DD
El Medication effects which could impair performance:

( El Physical therapy required. Frequency:
_ I1 » . I natient is industrial, physician signature is REQUIRED.
SIGNATURE AND TlTLE ¤P‘ r‘"'” P P TP P P PP P D P iPPP
' D6
{NAME (enum P LOCATION/ADDRESS P more
{ zusrvvf z e T gzre/— z—.e sw 7
r eeoez tnEv.2·ca) otsrmaurtom WHITE Z CHART · pink it cAuAnv . PATIENT I if I

Case 3:07-cv-03114-SI Document 48-14 Filed O9/O5/2008 Page 2 of 2
VISIT VERIFICATION/FAMILY LEAVE Health Care Provider Certification
M For the Patient ,
The visit verification form confirms that you have had a visit with your health care provider. Additional health certification
information is included on this copy of the form. This information meets the medical certification requirements of the Family and
’ Medical Leave Act(FMLA) and can be used to document and request family leave from your employer. Your employer should
also be able to answer any questions that you may have about family leave, including qualifications and eligibility.
For the Treating Health Care Provider I
Certification regarding "Serious Health Conditions" must be determined and completed by the treating health care provider only.
Ordinarily, unless complications arise, illnesses such as the common cold, flu, upset stomach, and headaches other than g
migraines do not qualify as “Serious Health Conditions". A "Serious Health Condition", as defined by the FMLA, means an illness,
injury, impairment, or physical or mental condition that involves one of the following:
_ _ \‘ A v` ‘ ~ ` I-,
‘l. HOSPITAL CARE ~ . 4. CHRONIC CONDITIONS REOUIRING TREATMENTS if ( I
Inpatient care (ie., an overnight stay) in a hospital, , A chronic condition which:
hospice, or residential medical care facility, including any a. requires periodic visits for treatment by a health care
2 period of incapacity or subsequent treatment in connection provider, or by a nurse or physicians assistant under
with or consequent to such inpatient care. direct supervision of a health care provider;
. b. continues over an extended periodhot time (including `
‘ ;?£5NOEEn;;U§C;RIxlllvgighan mma consecutive recurring episodes of a single underlying condition); and
l calgender days (?nc‘u¥Hng any Subsequent treatment or c. may cause episodic rather than a continuing period of
period of incapacity relating to the same condition), that mcapacny (eg" asthma' d,abet8S' Gm|BpSy' 6tc‘)'
am ·¤r¤·r·=S¢ I _ A _ _ s. PERMANENT/LONG-TERM CONDITIONS REOUIRING
3- T"°¤*m°h* (’”C’Ud*’$ €Xam’{[email protected]’0”$ Y0 d8Y€’{”’”€ lf? SUPERVISION A period of incapacity which is permanent
S8I'lOUS health COndItIOn EXISTS and evaluations ofthe or |°ng-tErm due to a Condition for which treatment may
00l7dlYl0Fl.' lives N0? l”€’Ud€ ’0Ufl”l? Phi/$l€·?’ €X3m$· BYE not be effective. The employee or family member must be ,
Oi d€”Ya’ exams} h”° °' mm? hmyhs hV_8 health Cath _ under the continuing supervision ot, but need not he
ll'0V'd€'; hV ll hum- OT l)hY$'°'ah S asslstllhl Uhdhl lhlhct receiving active treatment by, a health care provider.
S¤r>¤rv·S·¤¤ el 3 lleallll care P'0Vld€l· ¤r bv ll provider ¤l Examples include AlZhelmer’s, a severe simile, OT me
health care seniices (e.g., physical therapist) under terminal Stages of 8 disaasa
orders of, or on referral by, a health care provider; or
b.Treatment by a health care provider on at least one 6. MULTIPLE TREATMENTS (NON-CHRONIC CONDITIONS)
occasion Any period of absence to receive multiple treatments
which results in a regimen ol continuing treatment (including any period of recovery therefrom) by a health
(includes for example, a course of prescription care provider or by a provider of health care seniices under ·
medication [eg., an antibiotic] or therapy requiring orders of, or on referral by, a health care provider, either for
special equipment to resolve or alleviate the health restorative surgery after an accident or other iniury, or for
condition; does not include for example, the taking of a condition that would llkely result ln a period ot
over—the-counter medications such as aspirin, incapacity ot more than three consecutive calender days
antihistamines, or salves; or bed rest, drinking fluids, in the absence ot medical intervention or treatment, such
exercise, and other similar activities that can be initiated as cancer (chemotherapy, radiation, etc.), severe arthritis
without a visit to a health care provider) under the (physical therapy), kidney disease (dialysis). ·
supervision of the health care provider.
3. PREGNANCY
Any period of incapacity due to pregnancy, or for
prenatal care.
fn
7
‘·° . ..
96082 (REV.2-O3) REVERSE DISTRIBUTION: WHITE ¤ CHART · PINK & CANAFIY - PATIENT ·. r · 4 (

Case 3:07-cv-03114-SI

Document 48-14

Filed 09/05/2008

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Case 3:07-cv-03114-SI

Document 48-14

Filed 09/05/2008

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