Page 4 of 4
Employee Name:
(9)
Due to the condition, the patient (
for treatment(s) and/or recovery.
was /
will be)
incapacitated for a continuous period of time, including any time
Provide your best estimate of the beginning date
(mm/dd/yyyy)
and end date
(mm/dd/yyyy).
for the period of incapacity.
(10)
Due to the condition, it (
was /
is /
will be)
medically necessary for the employee to be absent from work to
provide care for the patient on an intermittent basis (periodically), including for any episodes of incapacity i.e., episodic flare-ups. Provide your
best estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.
Over the next 6 months, episodes of incapacity are estimated to occur times per
(
day week month)
and are likely to last approximately (
hours days)
per episode.
Signature of Health Care Provider Date:
(mm/dd/yyyy)
Definitions of a Serious Health Condition (See 29 C.F.R. §§ 825.113-.115)
Inpatient Care
•
An overnight stay in a hospital, hospice, or residential medical care facility.
•
Inpatient care includes any period of incapacity or any subsequent treatment in connection with the overnight stay.
Continuing Treatment by a Health Care Provider (any one or more of the following)
Incapacity Plus 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 either:
o Two or more in-person visits to a health care provider for treatment within 30 days of the first day of incapacity unless
extenuating circumstances exist. The first visit must be within seven days of the first day of incapacity; or,
o At least one in-person visit to a health care provider for treatment within seven days of the first day of incapacity, which
results in a regimen of continuing treatment under the supervision of the health care provider. For example, the health
provider might prescribe a course of prescription medication or therapy requiring special equipment.
Pregnancy: Any period of incapacity due to pregnancy or for prenatal care.
Chronic Conditions: Any period of incapacity due to or treatment for a chronic serious health condition, such as diabetes,
asthma, migraine headaches. A chronic serious health condition is one which requires visits to a health care provider (or nurse
supervised by the provider) at least twice a year and recurs over an extended period of time. A chronic condition may cause
episodic rather than a continuing period of incapacity.
Permanent or Long-term Conditions: A period of incapacity which is permanent or long-term due to a condition for which
treatment may not be effective, but which requires the continuing supervision of a health care provider, such as Alzheimer’s
disease or the terminal stages of cancer.
Conditions Requiring Multiple Treatments: Restorative surgery after an accident or other injury; or, a condition that would
likely result in a period of incapacity of more than three consecutive, full calendar days if the patient did not receive the treatment.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29
C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number. The Department of Labor estimates that it will take an average of 15 minutes for respondents to complete this
collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden
estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the
Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington,
D.C. 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
Form WH-380-F, Revised June 2020