Fax this completed Certification of Health Care Provider to Human Resource Management at (909) 658-6144 CERTIFICATION OF HEALTH CARE PROVIDER none Te Clfoia Genie atin Nondaininaton At of 2011 (COIN) pris employes {ober ove eae eine olan etn aval or ay eb ae india! expt spily slowed by uw To Gply ihe Ack we ae king Got you a0 provi any froie infra won rapondig to his rout for atest immton “Cetin as dele ES ae arsine nv onda enters ge a, iron SITY tong the anf of cur ce rei sly mente ofthe in abd elsif Fe tT eeepc et oes oeeentnncnd pico eevtrnnwaanrcee e HEALTH ‘the individual. “Gex@tic Information” does not include information about an individual's sex or age. SECTION I: EMPLOYEE INFORMATION. EMPLOYER COMPLETES: Employee's Name: AM, AVAL. Employee we:_O YY 8697 Employee's Signature: pae_//- 29-/2 (SECTION Ii: PATIENT INFORMATION HEALTH CARE PROVIDER COMPLETES j Paion’s Name: EDUARDO T- PWAVA L IF dependent tld, Age: Relationship t employee: CiSelf PX Spouse CiDomestic Partner Parent (IChild-Under 18 OChild- 18 or over Other elationhpt Does the patient's condition warrant the participation of the employeo for basic medical needs sach as hygiene, nutrition, safety, transportation, psychological comfort, and reassurance for the seriously-ill family member? CYes CNo ‘SECTION I: MEDICAL INFORMATION ~ musi be filled out [HEALTH CARE PROVIDER DO NOT DISCLOSE THE UNDERLYING DIAGNOSIS WITHOUT CONSENT OF THE PATIENT Please see the definitions of “Serious Health Condition” under the FMLA on the back of this form. 1. Check the description of the serious health condition for the patient: (1) G2) 03) 1 OS) 016) ONONE 2. Irelated to Pregnancy (3), please specify the date of birth or expected delivery date: 3. Approximate date condition commenced: {1 /7: /& First reated date: 1/22) [8 4, Most recent Dr. vist or treatment date:_/ 129/18 Any scheduled Dr. visit: 5. Docs employee need time off work? CI YegXINo Time off work is: (Continuous OR. Ci intermittent, Tees, fll in the dates below: Employee's Anticipated Leave of Absence Period: jaca to [samt ‘Ariapatcd Lesve Bogs Date”~Anipatsd eave Bnd Date (SECTION TV: INTERMITTENT LEAVES ONLY [HEALTH CARE PROVIDER COMPLE ] Please estimate how often the employee might expect tobe off work for incapacity or medical appointments: Frequency: Duration: Upto___absence(s) per month Upto hhour() perabsenee OR Upto____day(s) per absence (SECTION V: HEALTH CARE PROVIDER INFORMATION AND SIGNATURE, HEALTH CARE PROVIDER COMPLETES 1 Print Name: FRADIS S {0e?- Practce/Medical Specialty: Oye Phone: QELON OYE, | Fax:_(\ Signature of health care provider: Fax this completed Certification of H Provi fuman Resource Management at (909) 688-6144