Form WH-380-F, Revised June 2020
SECTION I - EMPLOYER
SECTION II - EMPLOYEE
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
The Family and Medical Leave Act (FMLA) provides that an employ er may require an employee seeking FMLA leave to care for a f amily
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. § 825.305. The employer must give the employee at least 15 calendar days to provide the certification. If the empl oyee
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 provider f or the
information necessary for a complete and sufficient medic al certification, which is set out at 29 C.F.R. § 825.306. Yo u 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 medical information, medical certifications, recertifications, or medical
histories of employees or employees’ family members crea ted for FMLA purposes as confidential medical records in se parate 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 Nondiscriminati on Act applies.
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.)
Please complete and sign Section II before providing this f orm to your family member or your family member’s health care pr ovider. The FMLA
allows an employer to require that you submit a timely, complete, and s ufficient medical certification to support a request for FMLA leave due to
the serious health condition of your family member. If requested by your employer, your response is required to obtain or retain the benefit of
the FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). You are respon sible for making sure the medical certification is provided to your
employer within the time frame requested, which must be at l east 15 calendar days. 29 C.F.R. §§ 825.305-825.306. Failure to pr ovide a
complete and sufficient medical certification may result in a denial of your FMLA leave request. 29 C.F.R. § 825.313.
Name of the family member for whom you will provide care:
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 w as married, including in a common law
marriage or same-sex marriage. The terms “child” and “parent” include in loc o parentis relationships in which a person assumes the
obligations of a parent to a child. An employee may take FMLA leave to care for an individ ual who assumed the obligations of a parent to
the employee when the employee was a child. An employee may also ta ke FMLA leave to care for a child for whom the employee has
assumed the obligations of a parent. No legal or biological relati onship is necessary.