Fillable Purdue University Fmla Medical Certification Form (Page 3 of 3) in pdf

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Description of Serious Health Condition

An illness, injury, impairment, or physical or mental condition that involves:

a) Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity (for

purposes of this policy, defined to mean inability to work, attend school, or perform other daily regular activities due to the Serious

Health Condition, treatment therefore, or recovery there from), or any subsequent treatment in connection with such inpatient care; or

b) Continuing treatment by a Health Care Provider.

A Serious Health Condition involving continuing treatment by a Health Care Provider includes any one or more of the following:

A period of incapacity and treatment (i.e., inability to work, attend school, or perform other regular daily activities due to the Serious

Health Condition, treatment therefore, or recovery therefrom) of more than three consecutive, full calendar days, including any

subsequent treatment or period of incapacity relating to the same condition, that also involves:

Treatment two or more times within 30 days of the first day of incapacity, unless extenuating circumstances exist, by a Health

Care Provider, by a nurse or physician 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

Treatment by a Health Care Provider on at least one occasion, which results in a regimen of continuing treatment under

the supervision of the Health Care Provider.

The treatment referenced in paragraphs (1) and (2) must be in-person visits to a Health Care Provider. The first (or only) in-person

treatment visit must take place within seven days of the first day of incapacity.

Any period of incapacity due to pregnancy or for prenatal care.

Any period of incapacity or treatment for such incapacity due to a chronic Serious Health Condition. A chronic Serious

Health Condition is one that:

Requires periodic visits (defined as at least twice a year) for treatment by a Health Care Provider, or by a nurse or

physician assistant under direct supervision of a Health Care Provider;

Continues over an extended period of time (including recurring episodes of a single underlying condition); and

May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.)

A period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. The Eligible

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.

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 of more than three consecutive, full

calendar days in the absence of medical intervention or treatment. Examples include cancer (chemotherapy, radiation, etc.),

severe arthritis (physical therapy), or kidney disease (dialysis).

For the purposes of this definition, treatment includes, but is not limited to, 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 may include, for example, a course of prescription medication. A regimen of continuing

treatment that includes the taking of over-the-counter medications, such as aspirin or antihistamines, or bed rest, exercise, or other

similar activities that can be initiated without a visit to a Health Care Provider, is not, by itself, sufficient to constitute a regimen of

continuing treatment for purposes of FMLA leave.

Examples of conditions that do not meet the definition of a Serious Health Condition and do not qualify for FMLA leave include:

Conditions for which cosmetic treatments are administered (such as most treatments for acne or plastic surgery), unless

inpatient hospital care is required or unless complications develop.

Ordinarily, unless complications arise, the common cold, the flu, ear aches, upset stomach, ulcers, headaches other

than migraine, routine dental or orthodontia problems, etc..

Substance abuse may be a Serious Health Condition if the conditions of this section are met. However, FMLA leave may only be taken

for treatment for substance abuse by a Health Care Provider or by a provider of health care services on referral by a Health Care

Provider. Absence because of the Eligible Employee’s use of the substance, rather than for treatment, does not qualify for FMLA leave.

Absences attributable to incapacity due to pregnancy or a chronic Serious Health Condition may qualify for FMLA leave even though

the Eligible Employee or the Covered Family Member does not receive treatment from a Health Care Provider during the absence, and

even if the absence does not last more than three consecutive, full calendar days. For example, an Eligible Employee with asthma may

be unable to report for work due to the onset of an asthma attack or because the Eligible Employee’s Health Care Provider has advised

the employee to stay home when the pollen count exceeds a certain level. An Eligible Employee who is pregnant may be unable to

report to work because of severe morning sickness.

Purdue University Fmla Medical Certification Form Page 3

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