Certification By Employee'S Health Care Provider For Employee'S Serious Illness

FMLA DESCRIPTION OF SERIOUS HEALTH CONDITION

A "Serious Health Condition" means an illness, injury, impairment, or physical or mental condition that involves one

of the following:

Hospital Care

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

period of incapacity or subsequent treatmene in connection with or consequent to such inpatient care.

Absence Plus Treatment

A period of incapacity of more than three full consecutive days (including any subsequent treatment or

period of incapacity relating to the same condition), that also involves:

a) 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'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,

(b) Treatment by a health care provider on at least one occasion which results in a regimen of continuing

treatment

under the supervision of a health care provider.

The requirements for treatment by a health care provider means an in-person visit to a healthcare provider.

The first (or only) in-person treatment visit must take place within seven days of the first day of incapacity.

Pregnancy

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

Chronic Conditions Requiring Treatments

A chronic condition which;

(a) Requires periodic visits (at least twice a year) for treatment by a health care provider, or by a nurse or

physician's assistant under direct supervision of a health care provider;

(b) Continues over an extended period of time (including recurring episodes of a single underlying

condition); and

(e.g., asthma, diabetes, epilepsy).

Permanent/Long-term Conditions Requiring Supervision

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 include Alzheimer's, a severe stroke, or the

terminal stages of a disease.

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 full 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).

FMLA

relates only to the condition lix which the employee

Here and elsewhere on this form. the information

leave,

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.

A regimen of continuing treatment includes. for example, a course of prescription medication (e.g. antibiotic) or therapy

requiring special equipment to restore or alleviate the health condition.

regimen of continuing treatment does not include

the taking of over-the-counter medications such

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.

"Incapacity," for purposes of FMLA. is defined to mean inability to work, attend school or perform otber regular daily

activities due to the serious health condition. treatment therefore, or recovery therefrom.

APWU

Form

1- revised 5/24/12

Page 2

Certification By Employee'S Health Care Provider For Employee'S Serious Illness - Fmla Page 2

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