110 STAT. 4360 CONCURRENT RESOLUTIONS—APR. 16, 1996 c. If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g., prescription drugs, physical therapy requiring special equipment): 7.a. If medical leave is required for the employee's absence from work because of the employee's own condition (including absences due to pregnancy or a chronic condition), is the employee unable to perform work of any kind? b. If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee's job (the employee or the employer should supply you with information about the essential job functions)? If yes, please list the essential functions the employee is unable to perform: c. If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment? 8.a. If leave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation? b. If no, would the employee's presence to provide psychological comfort be beneficial to the patient or assist in the patient's recovery? c. If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need: (Signature of Health Care Provider) (Tjrpe of Practice) (Address) (Telephone number) To be completed by the employee needing family leave to care for a family member: State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule: (Employee signature) (Date) A "Serious Health Condition" means an illness, injury, impairment, or physical or mental condition that involves one of the following: 1. 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 treatment in connection with or consequent to such inpatient care. 2. Absence Plus Treatment.— ^A period of incapacity ^ of more than three consecutive calendar days (including any subsequent treatment or period of incapacity ^ relating to the same condition), that also involves: (1) Treatment 3 two or more times by a health care provider, by a nurse or phy- sician'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; or (2) 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. 3. Pregnancy.—Any period of incapacity due to pregnancy, or for prenatal care. 4. Chronic Conditions Requiring Treatments.— ^A chronic condition which: (1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under direct supervision of a health care provider; (2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and (3) May cause episodic rather than a continuing period of incapacity ^ (e.g., asthma, diabetes, epilepsy, etc.). 5. 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
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