The employer must give the employee at least 15 calendar days to provide the certification.
Section I: either the employee or the employer may complete Section I.
Optional form: use of this form is optional; it asks the health care provider for the information necessary for a complete and sufficient medical certification.
Medical certification: if the employee fails to provide complete and sufficient medical certification, his or her FMLA leave request may be denied.
Health care provider: limit your response to the medical condition for which the employee is seeking FMLA leave.
Part B: after completing Part A, complete Part B to provide information about the amount of leave needed.
| Question | Answer |
|---|---|
| Form Name | Form WH-380-F |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 85 |
| Avg. time to fill out | 15 min |
| Edition | June 2020 |
| Issuing agency | U.S. Department of Labor Wage and Hour Division |
| Where to return | The patient |
| Other names | WH-380-F, WH380F, WH 380 F, Form WH-380-F, WH-380-F form, Certification of Health Care Provider for Family Member's Serious Health Condition |
| Official source | Form WH-380-F (Rev June 2020), U.S. Department of Labor |