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- Click ‘Get Form’ to open the human cgflmatop printable in the editor.
- In Part A, enter the employee’s name, last day worked, classification, work unit, department contact, and their phone number. Ensure you attach a copy of the employee’s job description.
- For Part B, as the employee, complete your daytime contact phone number and regular work schedule. Be mindful to return this form within 15 calendar days.
- In Part C, provide your health care provider with the form. They will need to fill out their details and answer specific medical questions regarding your condition.
- In Part D and E, ensure that your health care provider accurately answers questions about your medical facts and the amount of time needed for leave. This includes any follow-up treatments or modifications required for your job.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2009 | 4.8 Satisfied (100 Votes) |
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