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DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6ElA4FD76
<br /> CONFIDENTIAL
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<br /> A"Seri ous Health Condition"means an illness,injury Impairment,or physical or mental condition that involves one of the
<br /> following:
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<br /> 1. Hospital Care
<br /> Inpatient care(i.e.,an overnight stay)In a hospital,hospice,orresidential medical carefacility,Including any period of
<br /> Incapacity?or subsequent treatment in connection with or consequent to such Inpatient care. !_
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<br /> 2. kbsencePlusTreatment
<br /> (a) Aperiod Of Incapacity?ofmore than three consecutive calendar days(Including any subsequent treatment or
<br /> period of IncapacIty2 relating to the same condition),that also involves:
<br /> (1) Treatments two or more times by a health care provider,by a nurse or physician's assistant under direct
<br /> supervision of a healthcare provider,or by a provider of healthcare services(e.g.,physical therapist) s
<br /> under orders of,or on referral by,a health care provider;or
<br /> (2) Treatment by a healthcare provideron at least one occasion which results in a regimen of continuing {
<br /> treatment4 under the supervision of the health care provider,
<br /> 3, Pregnancy
<br /> Any period Of Incapacity due to pregnancy,or for prenatal care.
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<br /> 4, ChronicConditivnsRegyirLgTreatments
<br /> A chronic condition which:
<br /> (1) Requires periodic visits for treatment by a healthcare provider,or by a nurse or physician's assistant under
<br /> direct supervision of health care provider;
<br /> (2) Continues overan extended period of time(Including recurring episodes of a single underlying condition);
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<br /> (3) May cause episodic rather than a continuing period of incapacity2(e.g.,asthma,diabetes,epilepsy,etc.).
<br /> 5, )?grmanenliLong-term Conditions Reguir)gg&perylsl gn
<br /> A period of Incapacity2 which is permanent or tong-term due to a condition for which treatment may not be effective,The
<br /> employee orfamily membermust be underthe continuing supervision of,but need not be receiving active treatment
<br /> by,a health care provider, Examples include Mzhelmees,a severe stroke,or the terminal stages of a disease.
<br /> 6, Mulkiole Treatments(Nan-Chronic Conditions)
<br /> Any period of absence to receive multiple treatments(including any period of recovery therefrom)by a health care
<br /> provider or by a provider of health care services under orders of,or an referral by,a health care provider,either for
<br /> restorative surgery after an accident or other Injury,or for a condition that would likely result in a period c f Incapacity?
<br /> of more than three consecutive calendar days in the absence of medical Intervention or treatment,such as cancer
<br /> (chemotherapy,radiation,etc,),severe arthritis(physical therapy),and kidney disease(dialysis).
<br /> This optional form may be used by employees to satisfy a mandatory requirement to furnish a medical certification(when requested)from
<br /> a health care provider,including second or third opinions and recertification(23 CPR 825.306).
<br /> Note;Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
<br /> 3 Treatment includes amminaitons to dalarmina Ifaaadoue health condition exists and evaluallons of the condition.Treatment dons not include routine
<br /> physical examinations,eye examinations,ordental examinations,
<br /> A A regimen nfcontinuing treatmentindudes,forexample,a course afproscripton medication(a.g.,an antiblotic)or therapy requiring special equipment
<br /> to resolve or alleviate the health condition.A regimen of treatment does not Include the taking of over-the-counter medications such as aspidn,
<br /> antihistamines,or anivan;or bad-rest,ddnldng fluids,ammise,and tither similar aotvities that can be initialed vAthout a vislt to a health care pmvldar.
<br /> Public Burden Statement
<br /> We estimate that it will take an average of 20 minutes to complete this collection of information,Including the lime for reviewing
<br /> instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the
<br /> collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of
<br /> Information,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,Department
<br /> of Labor,Room S-3502,200 Constitution Avenue,NN,Washington,D.C.20210.
<br /> DO NOT SEND THE COMPLETED FORM TO THiS OFFICE,IT GOES TO THE EMPLOYEE,
<br /> Non 4aril ll.S ePO:�O6D4e1854r7S505
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