FMLA Certification of Health Care Providerfor Family Member’s Serious Health Condition

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

Form WH-380-F, Revised June 2020

Page 1 of 4

Certification of Health Care Provider for

Family Member’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 leave to care for a family

member with a serious health condition to submit a medical certification issued by the family member’s health care provider. 29 U.S.C. §§ 2613,

2614(c)(3); 29 C.F.R. § 8 25.305. 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

SECTION I - EMPLOYER

SECTION II - EMPLOYEE

WHD website at www.dol.gov/agencies/whd/fmla.

Either the employee o r the employer may complete Section I. While use of this form is optional, this form asks the health care provider for the

information necessary for a complete and sufficient medical 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. Additionally, 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 me dical information, medical certifications, recertifications, or medical

histories of employees or employees’ family members created fo r 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)

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.)

Please complete and sign Section II before providing this form to your family member or your family member’s health care provider. The FMLA

allows an employer to require that you submit a timely, complete, and s ufficient medical certification to support a request f or FMLA leave due to

the serious health condition of your family member. If requested by your employer, your response is required to obtain or ret ain the benefit of

the FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). You are responsible for making sure the medical certification is provided to your

employer within the time frame requested, which must be at least 15 calendar days. 29 C.F.R. §§ 825.305-825.306. Failure to provide a

complete and sufficient medical certification may result in a denial of your FMLA leave request. 29 C.F.R. § 825.313.

(1)

Name of the family member for whom you will provide care:

(2)

Select the relationship of the family member to you. The family member is your:

Spouse Parent Child, under age 18

Child, age 18 or older and incapable of self-care because of a mental or physical disability

Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in a common law

marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which a person assumes the

obligations of a pare nt to a child. An employee may take FMLA le ave to care for an individual who assumed the obligations of a parent to

the employee when the employee was a child. An employee may also take FMLA leave to care for a child for whom the employee has

assumed the obligations of a parent. No legal or biological relationship is necessary.