Washington University In St. Louis - Genetic Information Nondiscrimination Act (Gina) Fmla Certification Disclosure Form
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1Genetic Information Nondiscrimination Act (GINA)
FMLA Certification Disclosure
To be completed as an addendum to:
Certification of Health Care Provider for Employee’s Serious Health Condition (DOL Form WH-380-E)
Certification of Health Care Provider for Family Member’s Serious Health Condition (DOL Form WH-380-F)
Certification for Serious Injury or Illness of Covered Servicemember – for Military Family Leave (DOL Form WH-385)
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. “Genetic information” as defined by GINA, includes an individual’s
family medical history, the results of an individuals’ or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.
Please return this signed form to your department administrator/Human Resources with the appropriate completed
“Certification of Health Care Provider” Form.
Date: ________________________________________
Employee Signature: _____________________________________
Date: ________________________________________
Healthcare Provider’s Signature: ____________________________
Printed Name of Healthcare Provider: __________________________________
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