Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 3
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4PART B: AMOUNT OF LEAVE NEEDED
5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,
including any time for treatment and recovery? ___No ___Yes.
If so, estimate the beginning and ending dates for the period of incapacity: _______________________
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced
schedule because of the employee’s medical condition? ___No ___Yes.
If so, are the treatments or the reduced number of hours of work medically necessary?
___No ___Yes.
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time
required for each appointment, including any recovery period:
____________________________________________________________________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
__________ hour(s) per day; __________ days per week from _____________ through _____________
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job
functions? ____No ____Yes.
Is it medically necessary for the employee to be absent from work during the flare-ups?
____ No ____ Yes . If so, explain:
____________________________________________________________________________________
____________________________________________________________________________________
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
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL
ANSWER.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Page 3
CONTINUED ON NEXT PAGE
Form WH-380-E Revised May 2015
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