Fillable Form P33a - Employee Medical Certificate

FEDERAL FMLA:

Under the federal FMLA, “Serious Health Condition” is defined as an illness, injury, impairment, or physical or mental

condition that involves:

Any period of incapacity or treatment related to inpatient care (i.e., an overnight stay in a hospital, hospice,

residential facility, OR

Continuing treatment by a health care provider.

“Continuing treatment” by a health care provider includes any one or more of the following:

1) Incapacity and 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:

Treatment two or more times within 30 days of the first day of incapacity, unless extenuating

circumstances exist, , 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.

Treatment means an in-person visit to a health care provider. The first (or only) in-person treatment

visit

must take place within seven (7) days of the first day of incapacity.

2) Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care.

3) Chronic Conditions Requiring Treatments: Any period of incapacity or treatment for such incapacity due

to a chronic condition which:

Requires periodic visits for treatment by a health care provider or by a nurse physician’s assistant

under direct supervision of 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. Examples: asthma, diabetes,

epilepsy.

4) Permanent/Long-term Conditions: A period of incapacity, 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: Alzheimer’s, a severe stroke, or the terminal stages of a disease.

5) 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 of more than

three consecutive calendar days in the absence of medical intervention or treatment. Examples: cancer

(chemotherapy, radiation, etc.) severe arthritis (physical therapy), and kidney disease (dialysis).

Note:

Substance abuse may be a serious health condition if the conditions mentioned above 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. On the other

hand, absence because of the employee’s use of the substance, rather than for treatment, does not qualify for FMLA leave.

Please Note: For the purposes of federal FMLA the following terms are defined to mean:

“Incapacity” – inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore,

or recovery therefrom.

“Treatment” – includes examinations to determine if a serious health condition exists and evaluations of the condition. It does not include

routine physical examinations, eye examinations, or dental examinations.

A “regime 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. It 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.

“Intermittent Leave” – is leave taken in separate blocks of time due to a single qualifying reason.

“Reduced Leave Schedule” – is leave schedule that reduces an employee’s usual number of working hours per work-week or hours per

workday. It is a change in the employee’s schedule for a period of time, normally from full-time to part-time.

Form P33a - Employee Medical Certificate - 2011 Page 3

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