This form is to be used by employee when requesting FMLA and medical documentation is not required pursuant to 513.36 and 515.5 of ELM..

 EMPLOYEE’S NAME

JOHN DOE

 Description of serious health condition (On the back of this form is the description of a "serious health condition" under FMLA. Does the patient’s condition qualify under any of the categories described? If so, please check the applicable category.)

 Date condition commenced:

6/26/95

 Probable duration of condition:

3 DAYS

 The employee must provide a completed Form PS 3971 for each pay period, noting type of leave requested.

 Employee’s Signature

JOHN DOE

Date

6/26/95