A “Serious Health Condition” means an illness, injury impairment, or physical or mental condition that involves one of the
following:
1. Hospital Care
Inpatient care (
i.e.
, an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of
incapacity
2
or subsequent treatment in connection with or consequent to such inpatient care.
2. Absence Plus Treatment
(a) A period of incapacity
2
of more than three consecutive calendar days (including any subsequent treatment or
period of incapacity
2
relating to the same condition), that also involves:
(1) Treatment
3
two 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 occasion which results in a regimen of continuing
treatment
4
under the supervision of the health care provider.
3. Pregnancy
Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Conditions Requiring Treatments
A chronic condition which:
(1) 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;
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition);
and
(3) May cause episodic rather than a continuing period of incapacity
2
(
e.g.
, asthma, diabetes, epilepsy, etc.).
5. Permanent/Long-term Conditions Requiring Supervision
A period of Incapacity
2
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 a 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
provider 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
2
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), and kidney disease (dialysis).
This optional form may be used by employees to satisfy a mandatory requirement to furnish a medical certification (when requested) from
a health care provider, including second or third opinions and recertification (29 CFR 825.306).
Note:
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
3
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.
4
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.
Public Burden Statement
We estimate that it will take an average of 20 minutes 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 of
information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, Department
of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE; IT GOES TO THE EMPLOYEE.
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*U.S. GPO: 2000-461-954/25505
