City of
Carson
701 E Carson Street Carson, CA 90745 Telephone (310) 952-1736 Fax (310) 830-2471
III. REQUESTED TIME OFF WORK:
A. Will the employee be incapacitated for a single continuous period of time, including time for treatment and recovery.
No Yes – provide start and end dates, below:
____________________________ _______________________________ ____________________________________
Leave Start Date Expected Leave End Date Expected Return to work date
B. Will the employee need intermittent time off due to this serious health condition?
No Yes – if Yes, are these absences medically necessary? No Yes, if so provide details below:
Frequency: ____________ hour/days per week/month, or: __________
_______________________ __________________________ Duration: _____________ hours per day, or: ______________
Intermittent Period Intermittent Period Will these absences be consecutive? No Yes
Start Date End Date -If yes, up to ____________days in a row.
*if period end date is not known, please provide an estimated date that re-evaluation will occur.
Estimate the treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment including recovery period:
Dates of Appointments Time Required Per Appointment Recovery Period Required
C. Will the employee need to work part-time or a reduced work schedule due to this serious health condition?
No Yes - if yes, is this schedule medically necessary? No Yes, if so provide details below:
_______________hours per work day, _____________days per workweek
_______________________ __________________________
Reduced Schedule Reduced Schedule
Start Date End Date
IV. Limited Authorization for Release of Health Care Information
_______________________________________________________ ________________________________________
Employee’s Name Employee’s Date of Birth
I authorize the release of any medical information necessary to complete this form. Knowingly providing false information directly, or
through another party, may result in adverse action against the employee.
_________________________________________________________________________ _______________________________________
Employee’s Signature Date
CERTIFICATION BY PROVIDER: By signing below you are certifying that the information you have provided is
accurate and complete, and that this information is based on your personal knowledge of the patient’s condition.
___________________________________________________ ______________________________ _________________________________
Provider’s Printed Name and Credentials Type of Practice Telephone Number
______________________________________________________________________________________ ________________________________
Provider’s Office Address (Street, City, State, Zip Code) Best times & Days to Call
__________________________________________________________________________ ___________________________________
Provider’s Signature (No stamps or Proxy Seals Accepted) Date