Free Declaration in Support - District Court of California - California

Case 3:07-cv—O3114-SI Document 44-6 Filed O9/O5/2008 Page 1 of 2
Exhibit

, · Case 3:07-cv-03114-Sl i;Docu ment 44-6 Filed O9/O5/200_8{ Page 2 of 2
PERMANENTE• bg yp if /1942%/7é/Q
VISIT VERIFICATIOII/FAMILY LEAVE Health Care Provider Certlllcatlon , /
I r . Patient Name
(This section must be completed and determined by trestlng provider only) _ _
t mz nova ruuaso reason; |¢*¤¤*¤*I•=¤¢•¤¤
Ei NO, does not have a “Serfous Health Condition" (see reverse for further information) OR
II2‘ Dvss, has a ·sen¤¤s Helm conumtw, as anime mlm (cfm tm); U 9 5E zé
1. Ci Hospital care 4. D Chronic condition requiring treatment
2. EI Absence plus treatment E1 ls currently incapacitated iunnim mee
3.l`ZIPregnancy Ellsnslcurrentlyintzpacitated
. 5. I] condltion requiring supervision l. I] Multiple treatments (non-chronic condition)
EI 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
Ei Estimated date of Surgery/ProcedurelDellvenc ..;............... A

El Diagnosis (Complete on patient request only):
TH ABOVE NAMED PERSON:
Wasseenalthlsofffoeonc / Z Oé []Ha.sbeeng` t advlceon:
Has been ill and unable to attend wont/school/physical education / zf D6 through 5
E] States he/she has been lll and unable to attend work/school/physical educa ......._....._______ through
I`] C•nr•turntofultdutl••vvltt•l4ORESTRlC110NSon 0I|
, [] C•np•rtlclpstelnamodItI•dworkprogr•mstarttng sndconttnulngto
I (Pf••s•not•:lfmodlff•dworItlsnot•vallabI•,tttIspstl•ntlsthenunablstovvorkforttilstlmepsrlod.)
|:]Restrfctions:... ...h0ursperday .._....___hoursperweek
BASED ON AN B-HOUR DAY EMPLOYEE CAN:
stand/walk .i....._..... minutes per hour ..i...__. total hours [I no restriction;
sit ....._........mlnutesperh0ur ...._.....__totalhours Dnorestrlctlons
drtve ...._...... minutes per hour ...._.___. total hours E1 no restriction;
LIFT/CARRY (Occasionally = up to '/• workday. Frequently = up to */s workday):
O—10lbs. Unotatall Eloccaslonally Ufrequentty [Inoreatnctiona
1t—25 lbs. I] not at all I] occasionally El frequently I] no restrictions
26-40lbs. Dnotatall Doccasfonally Dfrequently Elnoreetrictions
Can Iltt/carry up to _....._..._ lbs.
EMPLOYEE IS ABLE TO:
bend ljnotatall C]0ccssionaIIy [lfrequently Unoremrlctlons
squat [jnotatall Cloccasionally Ufrequently Elnoreetrictlone
. kneel [jnotetall Cloccasionally Ulrequently Dnoreetrlctlons
climb I] not at all [3 occasionally EI frequently I:] no restrictions
reachaboveshouldere Unotatall Doccaslonally Dfrequently Dnorestrlctions
perfonn repetitive hand motions U not at all El occasionally Cl frequently U no restrictions
ASSISTIVE DEVICES? (eg., cast, brace. crutches)
RESTRICTIONS:


OTHER:

TREATMENT PLAN:
E] Medication elfects which could lmpalr performance: § by §XH'B'T
g 2`TY hl
e 7
X - · we I] Physical therapy required. Frequency: g
9 s iz / 0% Liv
, ,,r, ` ‘
_ J1 tient is industrial, physician signature is REQUIRED.
I NA ' AN I ` ’ ‘. "
E __ t t) 06
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Case 3:07-cv-03114-SI

Document 44-6

Filed 09/05/2008

Page 1 of 2

Case 3:07-cv-03114-SI

Document 44-6

Filed 09/05/2008

Page 2 of 2