FMLA Certification for Serious Injury or Illness of a Veteran for Wage and Hour Division Military Caregiver Leave

• Legal Form Number: WH-385V
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

Certification for Serious Injury U.S. Department of Labor

or Illness of a Veteran for Wage and Hour Division

Military Caregiver Leave

(Family and Medical Leave Act)

_____________________________________________________________________

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE EMPLOYEE OMB Control Number: 1235-0003

Expires: 8/31/2021

Notice to the EMPLOYER

The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military caregiver leave

under the FMLA leave due to a serious injur y or illness of a covered veteran to submit a certification pro viding sufficient facts to

support the request fo r leave. 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 CFR 825.310. Employers must generally maintain records

and documents relating to medical certifications, recertifications, or medical histories of employees or employees ’ family members,

created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance

with 29 CFR 1630.14(c)(1), if the Americans with Disabiliti es Act applies, and in accordance with 29 CFR 1635.9, if the Genetic

Information Nondiscrimination Act applies.

SECTION I: For completion by the EMPLOYEE and/or the VETERAN for whom the employee is

requesting leave

INSTRUCTIONS to the EMPLOYEE and/or VETERAN: Please complete Section I before having Section II completed.

The FMLA permits an employer to require that an employee submit a ti mely, complete, and sufficient certification to supp ort a

request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If requested by the

employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. 2613, 2614(c)(3). Failure to

do so may result in a denial of an employee’s FMLA request. 29 CFR 825.310(f). The employer must give an employee at least 15

calendar days to return this form to the employer.

(This section must be completed before Section II can be completed by a health care provider.)

Part A: EMPLOYEE INFORMATION

Name and address of employer (this is the employer of the employee requesting leave to care for a veteran):

__________________________________________________________________________________________________

Name of employee requesting leave to care for a veteran:

_________________________________________________________________________________________________

First Middle Last

Name of veteran (for whom employee is requesting leave):

__________________________________________________________________________________________________

First Middle Last

Relationship of employee to veteran:

Spouse Parent Son Daughter Next of Kin  (please specify relationship):

Page 1 CONTINUED ON NEXT PAGE Form WH-385-V Revised May 2015