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 of

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

Expires: 6/30/2026

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.

(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 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.

(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 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.