Form Wh 380 E – Fill Out and Use This PDF

Certification of Health Care Provider for	U.S. Department of Labor
Employee’s Serious Health Condition	Wage and Hour Division
under the Family and Medical Leave Act
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR.	OMB Control Number: 1235-0003
RETURN TO THE PATIENT.	Expires: 6/30/2023

The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider. 29 U.S.C. §§ 2613, 2614(c)(3); 29 C.F.R. § 825.305. The employer must give the employee at least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient medical certification, his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the WHD website at www.dol.gov/agencies/whd/fmla.

SECTION I – EMPLOYER

Either the employee or the employer may complete Section I. While use of this form is optional, this form asks the health care provider for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R.

§825.306. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Additionally, you may not request a certification for FMLA leave to bond with a healthy newborn child or a child placed for adoption or foster care.

Employers must generally maintain records and documents relating to medical information, medical certifications, recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.

(1)	Employee name: _______________________________________________________________________________
	First	Middle	Last
(2)	Employer name: ________________________________________________ Date: _________________ (mm/dd/yyyy)
			(List date certification requested)
(3)	The medical certification must be returned by ________________________________________________ (mm/dd/yyyy)

(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s diligent, good faith efforts.)

(4)Employee’s job title: ___________________________________________ Job description ( is /  is not) attached.

Employee’s regular work schedule: __________________________________________________________________

Statement of the employee’s essential job functions: ____________________________________________________

____________________________________________________________________________________________________________________

(The essential functions of the employee's position are determined with reference to the position the employee held at the time the employee

notified the employer of the need for leave or the leave started, whichever is earlier.)

SECTION II - HEALTH CARE PROVIDER

Please provide your contact information, complete all relevant parts of this Section, and sign the form. Your patient has requested leave under the FMLA. The FMLA allows an employer to require that the employee submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to the serious health condition of the employee. For FMLA purposes, a “serious health condition” means an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider. For more information about the definitions of a serious health condition under the FMLA, see the chart on page 4.

You may, but are not required to, provide other appropriate medical facts including symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment. Please note that some state or local laws may not allow disclosure of private medical information about the patient’s serious health condition, such as providing the diagnosis and/or course of treatment.

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Form WH-380-E, Revised June 2020

Employee Name: ____________________________________________________________________________________________

Health Care Provider’s name: (Print) ____________________________________________________________________

Health Care Provider’s business address: ________________________________________________________________

Type of practice / Medical specialty: ___________________________________________________________________

Telephone: (___) ______________ Fax: (___) ______________ E-mail: _______________________________________

PART A: Medical Information

Limit your response to the medical condition(s) for which the employee is seeking FMLA leave. Your answers should be your best estimate based upon your medical knowledge, experience, and examination of the patient. After completing Part A, complete Part B to provide information about the amount of leave needed. Note: For FMLA purposes, “incapacity” means the inability to work, attend school, or perform regular daily activities due to the condition, treatment of the condition, or recovery from the condition. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29 C.F.R. § 1635.3(b).

(1)State the approximate date the condition started or will start: ___________________________________ (mm/dd/yyyy)

(2)Provide your best estimate of how long the condition lasted or will last: ____________________________________

(3)Check the box(es) for the questions below, as applicable. For all box(es) checked, the amount of leave needed must be provided in Part B.

Inpatient Care: The patient ( has been /  is expected to be) admitted for an overnight stay in a hospital,

hospice, or residential medical care facility on the following date(s): ______________________________

Incapacity plus Treatment: (e.g. outpatient surgery, strep throat)

Due to the condition, the patient ( has been /  is expected to be) incapacitated for more than three consecutive, full calendar days from ______________ (mm/dd/yyyy) to _____________ (mm/dd/yyyy).

The patient ( was /  will be) seen on the following date(s): _____________________________________

_______________________________________________________________________________________

The condition ( has /  has not) also resulted in a course of continuing treatment under the supervision of a

health care provider (e.g. prescription medication (other than over-the-counter) or therapy requiring special equipment)

Pregnancy: The condition is pregnancy. List the expected delivery date: _______________ (mm/dd/yyyy).

Chronic Conditions: (e.g. asthma, migraine headaches) Due to the condition, it is medically necessary for the patient to have treatment visits at least twice per year.

Permanent or Long Term Conditions: (e.g. Alzheimer’s, terminal stages of cancer) Due to the condition, incapacity

is permanent or long term and requires the continuing supervision of a health care provider (even if active treatment is not being provided).

Conditions requiring Multiple Treatments: (e.g. chemotherapy treatments, restorative surgery) Due to the condition,

it is medically necessary for the patient to receive multiple treatments.

None of the above: If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy) no additional information is needed. Go to page 4 to sign and date the form.

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Form WH-380-E, Revised June 2020

Employee Name: ____________________________________________________________________________________________

(4)If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks FMLA leave. (e.g., use of nebulizer, dialysis) _______________________________________________________

_____________________________________________________________________________________

PART B: Amount of Leave Needed

For the medical condition(s) checked in Part A, complete all that apply. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage.

(5)Due to the condition, the patient ( had /  will have) planned medical treatment(s) (scheduled medical visits) (e.g. psychotherapy, prenatal appointments) on the following date(s): ___________________________________________

_____________________________________________________________________________________________

(6)Due to the condition, the patient ( was /  will be) referred to other health care provider(s) for evaluation or treatment(s).

State the nature of such treatments: (e.g. cardiologist, physical therapy) ________________________________________

Provide your best estimate of the beginning date ________________ (mm/dd/yyyy) and end date ________________

(mm/dd/yyyy) for the treatment(s).

Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery (e.g. 3 days/week)

_____________________________________________________________________________________________

(7)Due to the condition, it is medically necessary for the employee to work a reduced schedule.

Provide your best estimate of the reduced schedule the employee is able to work. From ____________________

(mm/dd/yyyy) to __________________ (mm/dd/yyyy) the employee is able to work: (e.g., 5 hours/day, up to 25 hours a week)

_____________________________________________________________________________________________

(8)Due to the condition, the patient ( was /  will be) incapacitated for a continuous period of time, including any time for treatment(s) and/or recovery.

Provide your best estimate of the beginning date ___________________ (mm/dd/yyyy) and end date

________________ (mm/dd/yyyy) for the period of incapacity.

(9)Due to the condition, it ( was /  is /  will be) medically necessary for the employee to be absent from work 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.

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Form WH-380-E, Revised June 2020