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

• Legal Form Number: WH-380-E
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

Form WH-380-E, Revised June 2020

Page of

SECTION I - EMPLOYER

SECTION II - HEALTH CARE PROVIDER

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

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR.

RETURN TO THE PATIENT.

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 www.dol.gov/agencies/ 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.

(1)

Employee name:

First Middle Last

(2)

Employer name: Date: (mm/dd/yyyy)

(List date certification requested)

(3)

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.)

(4)

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.