Free Declaration in Support - District Court of California - California

Case 3:07-cv—O3114-SI Document 44-12 Filed O9/O5/2008 Page 1 012
Exhibit "K"

»— - ‘ 5/2008 Pa e2of2 ._
e Q&geéR3:07-cv—03114-SI . lQ0cument 44 12 Filed 09/0 I 2 pgljtl M H J. 2
PERMANENTE• A A lciclttéilczttrcswz
VISIT VERIFICATIDN/FAMILY LEAVE Health Care Provlder Certlfleatlea
(T his sectlon must be completed and determined by lreatlag provider only) .
. THE AIDVE NAMED PERSON: Qygq {EA)
· { E1 N0, does not have a "SerIous Health C0ndItIon" (see reverse lor further Information) OR ·
'`o‘‘; C] YES, has a 'Serlous Health Condition', as defined below (check one):
1. D Hoepltal care 4. E] Chronic oondltlon requlrlnq treatment
2. E] Absence plus treatment E] I: currently incapacitated IMPRINT mae
3.ElPreqnancy Elleeetcumntlylncapacltzted
8. I] Permanenmonq-umm condltlon requlrlnq supervlslon I. El Multiple treatments (non·cI1ronIc condition)
I] Has a 'Serlous Health Condition' and requires a lamlly member to take tlme off hom work to provide baslc medlcal, personal or safety needs, transportation. or
psycholoplcal comfort. The probable frequency and duration of this need ls A

, III Estimated date of Surgery/Procedure/Dellvery —........;_____
El Dlagnosls (Complete on patient request only):
THE ABOVE NAMED PERSON:
I:IWaaseenatthlsof·flce0n: l;lHasbeen nte phoneadvlcaon:
who been lll and unable to attend work/school/physical education thr
D States he/she has been ill and unable to attend work/school/physical educatlon --..__.___ through —.._;_______
El can return to lull durlee with N0 RESTRICUONS on OR

I] Can pertlclpate In a modlfled work program etartlng and contlnulng to ...___________
‘ (Please note: It modlfled work le not avallable, thle patlent Ie then unable to work for thla tlme period.)
l]Fleetrlctlone: ...— _hours perday .i—____hours perweek
BASED ON AN 0-HOUR DAY EMPLOYEE CAN:
stand/walk .—._;___ minutes per hour .—._______ total hours I] no rash-lotion;
alt -.—.____ minutes per hour _.....;__ total hours I] no restrlcuong
' drlva ..._._____ mlnutee per hour ._.. total hours I] no rggtrlctlgng
LIFTICARRY (Occasionally == up to ‘/» workday. Frequently = up to 'le workday):
O—1D lbs. EI not at all El occaslonally D frequently E] no restrlctlons
1l·25 lbs. El not at all L] occaslonally El frequently D no restrlctlons
26-40 lbs. I] not at all I:] occaslonally EI frequently El no restrlctlons
Cen Ilftlcerry up to .—..—____ Ibe. V
EMPLOYEE IS ABLE TO:
bend U not at all El occaslcnally lj frequently U no restrlctlons
squat El not at all U occaslonally I;} frequently E] no restrlctlone
L kneel L] not at all I] occasionally El frequently D no restrictions
cllmb D not at all Cl occasionally El frequently C] no restrlctlons
reach above shoulders El not at all E] occaslonally I] frequently C] no restrictions
perform repetitive hand motfone E] not at all El occasionally El frequently U no resfrlctlons
ASSISTIVE DEVICES? (e.g., cast, brace, crutches)
RESTRICTIONS:
OTHER:
TREATMENT PLAN:
El Medication effects which could Impalr performance: · . QXHIBIT
§
.%,,5% I;] Physical therapy required. Frequency: 5 _
J E S rz ge
I - ¤ ·f~
sl NA 2 _ A i tlent ls lnduetrlal, phyelclan signature is REQUIRED, in
S E7 M
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aaoez (REV.2-03) ursrmeurrcul wnrrs . chem · - rr e cananv . PATIENT

Case 3:07-cv-03114-SI

Document 44-12

Filed 09/05/2008

Page 1 of 2

Case 3:07-cv-03114-SI

Document 44-12

Filed 09/05/2008

Page 2 of 2