INPATIENT CARE (check one)
- 1A. Overnight stay in a hospital, hospice, or residential medical care facility.
- 1B. Any period of incapacity or subsequent treatment in connection with an overnight stay in the type of facility listed above.
CONTINUING TREATMENT (check at least one)
- 1A. Incapacity lasting more than 3 consecutive calendar days and that involves: (to check this, you must first check one of the following)
- a. Two or more treatments by or under the supervision, orders, or referral of a health care provider or
- b. One treatment by a health care provider followed by a regimen of continuing treatment under the supervision of the health care provider (e.g., prescription medications or therapy with specialized equipment but not over-the-counter medications or salves, bed- rest, fluid intake or exercise).
NOTE: Absent complications, this would not include the common cold, the flu, ear aches, upset stomach, minor ulcers, headaches other than migraine, routine dental or orthodontia problems, and periodontal disease.
- 1B. Any period of incapacity or subsequent treatment relating to the above condition.
- 2. Incapacity due to pregnancy or for prenatal care.
- 3. Incapacity or treatment for a chronic serious health condition that: (to check this, you must first check all of the following)
- a. Requires periodic visits for treatment by or under the direct supervision of a health care provider and
- b. Continues over an extended period (including recurring episodes) and
- c. May be episodic (e.g. asthma, diabetes, epilepsy).
- 4. Permanent or long term incapacity for which treatment may be ineffective and which requires the supervision of, but not necessarily treatment by, a health care provider (e.g. Alzheimer’s, severe stroke, terminal stages of disease).
- 5A. Absences to receive multiple treatments by or under the supervision, orders, or referral of a health care provider for: (to check this box, you must first check one of the following)
- a. Restorative surgery after an accident or injury or
- b. A condition that is likely to result in incapacity of more than 3 consecutive calendar days without medical intervention or treatment (e.g. cancer, severe arthritis, kidney disease).
- 5B. Any period of recovery relating to the above treatments.
Cite: 29 CFR §825.114.
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