Employee Name: ____________________________________________________________________________________________
PART C: Essential Job Functions
If provided, the information in Section I question #4 may be used to answer this question. If the employer fails to provide a
statement of the employee’s essential functions or a job description, answer these questions based upon the employee’s own
description of the essential job functions. An employee who must be absent from work to receive medical treatment(s), such
as scheduled medical visits, for a serious health condition is considered to be not able to perform the essential job functions
of the position during the absence for treatment(s).
(10) Due to the condition, the employee ( was not able / is not able / will not be able) to perform one or more
of the essential job function(s). Identify at least one essential job function the employee is not able to perform:
Health Care Provider _____________________________________________ Date _________________ (mm/dd/yyyy)
Definitions of a Serious Health Condition
(See 29 C.F.R. §§ 825.113-.115)
• An overnight stay in a hospital, hospice, or residential medical care facility.
• Inpatient care includes any period of incapacity or any subsequent treatment in connection with the overnight stay.
Continuing Treatment by a Health Care Provider (any one or more of the following)
Incapacity Plus Treatment: A period of incapacity of more than three consecutive, full calendar days, and any subsequent treatment
or period of incapacity relating to the same condition, that also involves either:
o Two or more in-person visits to a health care provider for treatment within 30 days of the first day of incapacity unles
tenuating circumstances exist. The first visit must be within seven days of the first day of incapacity; or
o At least one in-person visit to a health care provider for treatment within seven days of the first day of incapacity, which
esults in a regimen of continuing treatment under the supervision of the health care provider. For example, the healt
rovider might prescribe a course of prescription medication or therapy requiring special equipment
Pregnancy: Any period of incapacity due to pregnancy or for prenatal care.
Chronic Conditions: Any period of incapacity due to or treatment for a chronic serious health condition, such as diabetes, asthma,
migraine headaches. A chronic serious health condition is one which requires visits to a health care provider (or nurse supervised by
the provider) at least twice a year and recurs over an extended period of time. A chronic condition may cause episodic rather than a
continuing period of incapacity.
Permanent or Long-term Conditions: A period of incapacity which is permanent or long-term due to a condition for which
treatment may not be effective, but which requires the continuing supervision of a health care provider, such as Alzheimer’s disease
or the terminal stages of cancer
Conditions Requiring Multiple Treatments: Restorative surgery after an accident or other injury; or, a condition that would likely
result in a period of incapacity of more than three consecutive, full calendar days if the patient did not receive the treatment.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons
are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates
that it will take an average of 15 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the
Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
Page 4 of 4 Form WH-380-E, Revised June 2020
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