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Form Wh-380-F - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 4

7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily

activities? ____No ____Yes.

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of

flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode

every 3 months lasting 1-2 days):

Frequency: _____ times per _____ week(s) _____ month(s)

Duration: _____ hours or ___ day(s) per episode

Does the patient need care during these flare-ups? ____ No ____ Yes.

Explain the care needed by the patient, and why such care is medically necessary: ________________________

____

___

____

___

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

___________________________________________________________________________________________

______________________________________________ ____________________________________________

Signature of Health Care Provider

Date

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616;

29 C.F.R. § 825.500.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB

control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this

collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the

data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate

or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator,

Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

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Form WH-380-F Revised May 2015

Form Wh-380-F - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 4