CERTIFICATION form (continued)
Federal and Oregon Family and Medical Leave Acts
Important Information Regarding GINA: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits
employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or
family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you
do not provide any genetic information when responding to this request for medical information. ‘Genetic information’, as
defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic
tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual, or an individual’s family member or an embryo lawfully held by an individual
or family member receiving assistive reproductive services.
Definition of a “Serious Health Condition”
A “serious health condition” is defined as an illness, impairment, physical or mental condition that involves one
of the following:
1) Hospital care-
Inpatient care (i.e. overnight stay) 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.
2) Absence plus treatment-
A period of incapacity of more than three consecutive calendar days (including any period of incapacity or subsequent
treatment relating to the same condition), that also involves:
a) Treatments two or more times by a licenses healthcare provider, nurse, or physician’s assistant under direct
supervision of a healthcare provider, or by a provider of healthcare services (e.g. physical therapist) under orders
of, or on referral by, a healthcare provider or
b) Treatment by a healthcare provider on at least one occasion which results in a regimen of continuing treatment
under supervision of the healthcare provider.
1) Treatment includes examinations to determine if a serious health condition exists and evaluations of the
condition. Treatment DOES NOT include routine physical, dental or eye examinations.
2) 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, or any other similar activities that can be initiated without a visit
to a healthcare provider.
Any period of incapacity due to pregnancy, pregnancy-related illness, or for prenatal care.
4) Chronic conditions requiring treatments-
A chronic serious health condition is one which:
a) Required periodic visits for treatment by a healthcare provider, nurse, or physician’s assistant under direct
supervision of a healthcare provider;
b) Continues over an extended period of time (including recurring episodes of a single underlying condition; and
c) May cause episodic rather than continuing periods of incapacity (e.g. asthma, diabetes, epilepsy, etc.)
5) Permanent/long-term conditions requiring supervision-
A period of incapacity that 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 healthcare provider. Examples include Alzheimer’s, a severe stroke, or the terminal states 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 healthcare
provider or by a provider of healthcare services under orders of, or on referral by, a healthcare provider, either of
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), or kidney disease (dialysis).
Definition of “Incapacitated”
: Inability to work, attend school, or perform other regular daily activities due to the serious
health condition, treatment therefore, or recovery therefrom.
Directions regarding “Regimen of treatment” (question 7)
: If the patient is under your supervision, provide a general
description of such regimen, such as prescription drugs, physical therapy requiring special equipment. If the treatments
will be provided by another provider of health services, such as physical therapist, please state the nature of the