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Is required pursuant to 512.41, 513.36 and 515.5 of the ELM. Form PS 3971 must be completed by employee. Employee's names 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.) (1) (2) (3) (5) (4) 6 None of the above Without giving a specific diagnosis or prognosis, briefly note have the me.

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