Free Declaration in Support - District Court of California - California

Case 3:07-cv-03114-SI Document 48-10 Filed O9/O5/2008 Page 1 013
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VISIT VERIFICATION/FAMILY LEAVE Health Cara Provider Certification P t. t N ’
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ex Was seen at this office on: fz}? [ C'. K] Has given telephone advice on: {
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__, -. _f Has been ill and unable to attend wort;/schoovphysical education V 0 Q" through W ' E »’ l ‘·· E3
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F Cl States he/she has been ill and unable to attend work/school/physical educégn .;.;....._____ through ._;_..;______
lj Can retum to full dutles with N0 RESTRICTIONS on OR il
E Can participate in a modified work program starting and contlnulng to T;.._._;.____
(Please note: lf modified work ls not available, this patient ls then unable to work for this time period.)
El Flestrictions: ..._ hours per day ‘ .;_ hours per week fg
BASED ON AN 8-HOUR DAY EMPLOYEE CAN: ·
stand/walkt L_,.... rninutes per. hour) I total hours. _ . El no restrictions i
sit __i;__ minutes per hour _..;..__ total hours El no restrictions
__ drive , ;....;..;_ minutes per hour A ·_..__ total hours El no restrictions
LIFTICARFIY (Occasionally = up to 'le workday. Frequently = up to ’/e workday): — ,g
W 0-10 lbs. El not at all I:] occasionally I:] frequently El no restrictions '
11-25 lbs. Cl not at all I] occasionally I:] treqtjently El no restrictions
26-40 lbs. El not at all C1 occasionally I] frequently lj no restrictions
Can lift/carry up to ;...._.___ lbs. 4
EMPLOYEE IS ABLE TO: -
bend El not at all Cl occasionally El frequently El no restrictions
~\_ squat Cl not at all El occasionally El frequently El no restrictions Q;
kneel D not at all El occasionally [] frequently Cl no restrictions
{ climb El not at all El occasionally U frequently El no restrictions
reach above shoulders . I] not at all El occasionally Cl frequently El no restrictions
perform repetitive hand motions El not at all El occasionally D frequently El no restrictions
ASSISTIVE DEVICES? (e.g,, cast, brace, crutches)
RESTRICTIONS: ~

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Cl Medication effects which could impair performance: Q.;
D [I Physical therapy required. Frequency;
. _ A_,NOTEz· lf patient is industrial, physician signature is REQUIRED. tza
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Case 3:07-cv-03114-SI

Document 48-10

Filed 09/05/2008

Page 1 of 3

Case 3:07-cv-03114-SI

Document 48-10

Filed 09/05/2008

Page 2 of 3

Case 3:07-cv-03114-SI

Document 48-10

Filed 09/05/2008

Page 3 of 3