(1) Serious health condition
An illness, injury (including, but not limited to, on-the-job injuries), impairment, or physical or mental condition of the
employee or a child, parent, or spouse of the employee that involves either inpatient care or continuing treatment,
including, but not limited to, treatment for substance abuse. A serious health condition may involve one or more of the
(2) Hospital Care
Inpatient care in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent
treatment in connection with or consequent to such inpatient care. A person is considered an “inpatient” when a heath
care facility formally admits the patient to the facility with the expectation that the patient will remain at least overnight
and occupy a bed, even if it later develops that such person can be discharged or transferred to another facility and
does not actually remain overnight.
(3) Absence Plus Treatment
(A) A period of incapacity of more than three (3) consecutive calendar days (including any subsequent treatment or
period of incapacity
relating to the same condition), that also involves:
two (2) or more times by a health care provider, by a nurse or physician’s assistant under direct
supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under
orders of, or on referral by, a health care provider; or,
(2) Treatment by a health care provider on at least one (1) occasion which results in a regimen of continuing
under the supervision of a health care provider.
(4) Chronic Conditions Requiring Treatment
A chronic condition which:
(A) Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under direct
supervision of a health care provider;
(B) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(C) May cause episodic, rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
ent/Long-term Conditions Requiring Supervision
A period of incapacity which is permanent or long-term
due to a condition for which treatment may not be effective. The
employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a
health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages of disease.
(6) Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care
ider or by a provider of health care services under orders of, or on referral by, a health care provider either for
restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of
more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer
(chemotherapy, radiation, etc.), severe arthritis (physical therapy) kidney disease (dialysis).
Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine
physical examinations, eye examinations, or dental examinations.
A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to
resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the-counter medications such as aspirin, antihistamines,
or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.
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Employee’s Full Name: