FMLA Certification for Serious Injury orIllness of Covered Servicemember -- for Military Family Leave

Legal Form NumberWH-385
IssuerWage and Hour Division
SectionU.S. Department of Labor
Page 1 of 4 Form WH-385, Revi sed June 2020
Certification for Serious Injury or Illness of a U.S. Department of Labor
Current Servicemember for Military Caregiver Leave Wage 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: 6/30/2026
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave to care for a covered
servicemember with a serious illness or injury. The FMLA allows an employer to require an employee seeking FMLA leave
for this purpose to submit a medical certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the employee at
least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient 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, it asks the health care
provider for the information necessary for a complete and sufficient medical certification. You may not ask the employee
to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310. Recertificatio ns are
not allowed for FMLA leave to care for a covered servicemember. Where medical certification is requested by an
employer, an employee may not be held liable for administrative delays in the issuance of military documents, despite
the employee's diligent, good-faith efforts to obtain such documents. An employer requiring an employee to submit a
certification for leave to care for a covered servicemember must accept as sufficient certification invitational travel orders
(ITOs) or invitational travel authorizations (ITAs) issued to any family member to join an injured or ill servicemember at
the servicemember’s bedside. An ITO or ITA is sufficient certification for the duration of time specified in the ITO or ITA.
Employers must generally maintain records and documents relating to medical information, 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 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) This 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.)
SECTION II - EMPLOYEE and/or CURRENT SERVICEMEMBER
Please complete all Parts of Section II before having the servicemember’s health care provider complete Section III. The
FMLA allows an employer to require that an employee submit a timely, complete, and sufficient certification to support a
request for FMLA leave due to a serious injury or illness of a covered servicemember. If requested by your employer, your
response is required to obtain or retain the benefit of FMLA-protected leave.
PART A: EMPLOYEE INFORMATION
(1) Name of the current servicemember for whom employee is requesting leave:____________________________

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