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Certification of Health Care Provider for U.S. Department of Labor Employees Serious Health Condition (Family and Medical Leave Act)

The employee seeks to request for Family and Medical Leave Act leave due to one’s serious conditions.Download

Extracted Text for Proper Search

Page 1 
 Form WH-380-E  Revised May 2015 
Certification of Health Care Provider for    U.S. Department of Labor 
Employee’s Serious Health Condition
      Wage and Hour Division   
(Family and Medical Leave Act)                
 
  DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT  OMB Control Number: 1235-0003   	
 
 Expires:  5/31/2018  SECTION I: For Completion by the EMPLOYER
   
INSTRUCTIONS to the EMPLOYER:   	
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 .  Please complete Section I before giving this form to 
your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to 
provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must 
generally maintain records and documents relating to 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.  
  
Employer name and contact: __________________________________________________________________  
 
Employee’s job title:  _____________________________ Regular work schedule: _______________________  
 
Employee’s essential job functions: __________________________________________________________ ___ 
 
__________________________________________________________________________________________ 
 
Check if job description is attached:  _____ 
  SECTION I
I:  For Completion by the  EMPLOYEE  
INSTRUCTIONS to the EMPLOYEE:   
Please complete Section II before giving this form to your medical provider.  
The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to 
support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response 
is required to obtain or retain the benefit of FMLA protections.  29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a 
complete and sufficient medical certification may result in a denial of your FMLA request. 20 C.F.R. § 825.313. Your 
employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b). 
 
Your name: __________________________________________________________________________________ 
First          Middle          Last 
  S
ECTION I II: For Completion by  the HEALTH CARE PROVIDER    
INSTRUCTIONS to the HEALTH CARE PROVIDER:  Your patient has requested leave under the FMLA.  Answer, 
fully and completely, all applicable parts.  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. Limit your responses to the condition for which the employee is seeking 
leave.  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).   Please be sure to sign the form on the last page. 
 
Provider’s name and business address: ___________________________________________________________  
 
Type of practice / Medical specialty:  _________________________________________________________ ___ 
 
Telephone: (________)____________________________ Fax:(_________)_____________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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________________________________________________________________________________________
________________________________________________________________________________________	
PART A:  MEDICAL FACTS 
1.Approximate date condition commenced:  __________________________________
 ____________________
Probable duration of condition: ______________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a ho spital, hospice, or residential 
me
dical care facility ?
___ No
 ___
Yes. 
 If so, dates of ad

mission:
Date(s) you tr

eated the patient for condition:
Will the patient need to have treatment visits at least  twice per y	

ear due to the condition?  ___No  ___ Yes.
Was medication, other than over-the-counter  medication, prescribed?  ___	

No  ___Yes.
Was the patient referred to other health care  provider(s) for evaluation or treatme
nt (e.g. , phy
sical therapist)
?
____ No
   __
__
Yes

.  If so, state the nature of such  treatments and expected duration of treatment:
2. Is the medical condition pregnancy?  ___	

No   ___Yes.  If so, expected delivery date: ____________________
3. Use the information provided by the em	

ployer in Secti on I to an
swer this question.   	 If the em
ploy er fail
s to
provide a list  of the em
ployee’s essential 
functions or  a job descripti	

on, answer these questions based upon
the employee’s own description of his/her job functions.
Is the employee unable to perform any of his/her job func tions due to the condition:  ____ No ____  Yes.
If so, identify the job functi ons the em

ployee is unable to perform:
4. Describe other relevant medical facts, if any, rela ted to the condition for which the employee seeks leave
(such medical facts may  inc

lude symptoms, diagnosis, or  any regimen of continuing treatment such as the use
of specialized equipment):	
Page 2  	 CONTINUED ON NEXT PAGE  Form WH-380-E 
 Revised  May 2015

____________________________________________________________________________________ 
____________________________________________________________________________________ 
____________________________________________________________________________________ 
__________________________________________________________________________________________ 
__________________________________________________________________________________________ 
__________________________________________________________________________________________ 
__________________________________________________________________________________________ 
__________________________________________________________________________________________ 
__________________________________________________________________________________________ 	
PART B: AMOUNT OF LEAVE NEEDED 
5. Will the employee be incapacitated for a single contin uous period of time due to his/her medical condition,
including any time for treatment and recovery?  ___ No   ___Yes.	

 
If so, estimate the beginning and ending dates for the period of incapacity: _______________________ 
6. Will the employee need to attend follow-up treatme nt appointments or work part-time or on a reduced
schedule because of the employee’s me dical condition?  ___No ___Yes.
If so, are the treatments or the reduced num ber of hours of work m
e

dically necessary? 
___No  ___Yes. 

Estima te treatment schedule, if any, incl	

uding the dates of any scheduled appointments and the time 
required for each appointment, incl uding any recovery period:  
Estimate the part-time or reduced work  schedule the e
mploy
ee needs, if any : 
____ ______ 
hour(s) per d
ay
; 
___ ___
__

__ days per week
  from _____________ through ____	 _________ 
7. Will the condition cause episodic flare-ups periodically  preventing the employee from performing his/her job
functions?  ____	
No ____ Yes.
Is it medically necessary for the empl	

oyee to be absent from work during the flare-ups? 
____  No ____ 
Yes.  If so, explain:  
Based upon the patient’s medical histo ry	

 and your knowledge of t he medical condition, estimate the 
frequency of flare-ups and the duration of related inca pacity that th

e patient may have over the next 6 
months (e.g., 1 episode every 3 months lasting 1-2 days): 
  Frequency : _____ times pe r _____ week(s) _____ month(s) 
Duration: _____ hours or ___ day(s) per episode  
ADDITIONAL INFORMATION:  IDENTIFY QUE STION NUM	

BER WITH YOUR ADDITIONAL 
ANSWER. 	
Page 3  CONTINUED ON NEXT PAGE  Form WH-380-E 
Revised  May 2 015

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__________________________________________ __________________________________________ 
Signature of Health Care Provider Date 	
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT 
If submitted, it is mandatory for employers to retain a copy of th is disclosure in their records for three years. 29 U.S.C. § 2616; 29 
C.F.R.  § 825.500. Persons are n	

ot required to respond to this collection of  information unless it displays a currently valid OMB 
control nu	
 mber.  The Department of Labor estimates that it will  take an average of 20 minutes for respondents to complete this 
collection of information, including the time for reviewing inst ructions, 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, in cluding suggestions for reducing this burden, send them to the 
Administrator, Wage and Hour Division, U.S. Department of  Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 
20210.  DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. 	
Page 4  Form WH-380-E 
Revised  May 	2015
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