FMLA Certification of Health Care Providerfor Employee’s Serious Health Condition

Legal Form NumberWH-380-E
IssuerWage and Hour Division
SectionU.S. Department of Labor
Form WH-380-E, Revised June 2020
Page of
Certification of Health Care Provider for
Employee’s Serious Health Condition
under the Family and Medical Leave Act
U.S. Department of Labor
Wage and Hour Division
OMB Control Number: 1235-0003
Expires: 6/30/2026
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA prot ections because of a need
for leave due to a serious health condition to submit a me dical certification issued by the employee’s health care pro vider. 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 whd/fmla.
Either the employee or the employer may complete Section I. While us e of this form is optional, this form asks the health care provi der for the
information necessary for a complete and sufficient medi cal 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. Additio nally, 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 certificatio ns, recertifications, or medical
histories of employees created for FMLA purposes as confidential medic al records in separate files/records from the usual personn el files and
in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabili ties Act applies, and in accordance with 29 C.F.R. § 1635.9, if the
Genetic Information Nondiscrimination Act applies.
Employee name:
First Middle Last
Employer name: Date: (mm/dd/yyyy)
(List date certification requested)
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.)
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.)
Please provide your contact information, complete all relevant parts of this Section, and sign the form. Your patient has request ed leave under
the FMLA. The FMLA allows an employer to require that th e employee submit a timely, complete, and sufficient m edical certification to support
a request for FMLA leave due to the serious health condition of the em ployee. For FMLA purposes, a “serious health condition” means an
illness, injury, impairment, or physical or mental condition t hat involves inpatient care or continuing treatment by a health care provider. For
more information about the definitions of a serious health cond ition under the FMLA, see the chart on page 4.
You also 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 loc al laws may not allow disclosure of private medical
information about the patient’s serious health condition, such as pr oviding the diagnosis and/or course of treatment.

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