Possible, but no later than 15 calendar 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin with Part 1: Employee Information. Fill in your name, EID, phone number, department, and email addresses for both yourself and your supervisor. Don’t forget to sign and date this section.
  3. Move to Part 2: Medical Facts. This section must be completed by your health care provider. Ensure they provide detailed information about your condition, including symptoms and treatment plans.
  4. In Part 3: Need for Leave or Work Schedule Adjustments, your health care provider will indicate whether you need continuous or intermittent leave. They should specify dates and frequency of any required appointments.
  5. Review all sections for accuracy before submitting the form via fax or email as indicated at the top of the document.

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2024 4.7 Satisfied (24 Votes)
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2023 4.4 Satisfied (35 Votes)
2022 4.8 Satisfied (52 Votes)
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2020 4.2 Satisfied (46 Votes)
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