Get Leave Questionnaire Form

Completing the Leave Questionnaire Form online can seem daunting, but this guide will walk you through each section step-by-step. By following these instructions, you will ensure that all necessary information is accurately provided.

Follow the steps to complete the Leave Questionnaire Form

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by checking all applicable boxes in Step 1. This section includes options for State Disability, Private Disability, FMLA, and Paid Family Leave.
3. In Step 2, you will need to indicate whether you have a Visit Verification of Treatment (VOT) from your treating physician. If you do, check 'Yes'; if not, select 'No'. Then, provide the Patient Name, Medical Record Number, Phone Number, SSN, Name of Treating Physician, and the specific condition if applicable. If the condition is pregnancy, include the due date and expected delivery date.
4. For Step 3, if you are claiming State or Private Disability, enter the First Date Unable to Work and the Estimated or Actual Return to Work Date.
5. Moving to Step 4, answer whether you allow your employer to request medical facts or specific condition information from Kaiser by checking 'Yes' or 'No' and providing your initials. Then, indicate if the Family Medical Leave Act (FMLA) is for a family member other than yourself. If 'Yes', enter your name and relationship to the patient. Fill in the FMLA start and end dates, and if FMLA is for an ongoing chronic condition, specify how many episodes per month and how many hours or days off are required.
6. In Step 5 for Paid Family Leave (PFL), provide the number of hours per day required to care for the family member, and indicate the Start and End Dates of Care.
7. Once all sections are completed, review the information for accuracy. You can then save your changes, download, print, or share the form as needed.

Take the next step and complete your Leave Questionnaire Form online today.