FMLA Questionnaire

This field is for validation purposes and should be left unchanged.

If records are being requested by a legal guardian or caregiver, the Power of Attorney forms need to be sent to NCF before records can be released.

Patient first name(Required)

Patient last name(Required)

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Date(Required)

Person Receiving Medical Records(Required)

If records are being requested by a legal guardian or caregiver, the Power of Attorney forms need to be sent to NCF before records can be released.

What is the condition for which you are seeking FMLA leave?

What date did the condition or disability begin?

Have you been hospitalized for this condition?

Yes

Which hospital?

When did hospitalization occur?

What is your current job title, description, and necessary duties?

What functions of your job are you unable to complete due to your condition or disability?

Which symptoms of your condition are preventing or restricting your ability to perform the duties of your job?

What accommodations are you requesting? Please be specific.

Will you be incapacitated for a continuous period of time?

Yes

Is this a continuous leave based on the above medical condition?

What are the beginning and end dates for the period of incapacity?

Begin Date

End Date

When do you expect to return to work?

Is this request for intermittent FMLA leave?

Yes

Will this condition cause episodic flare-ups (such as migraine, epilepsy, or multiple sclerosis)?

Yes

Estimate the frequency and duration of the flare-ups that impair your ability to work:

Please provide an estimate of how long a flare-up of your condition will prevent you from working:

Patient name(Required)

Rev 8.26.2024