Form Wh-385 - Certification For Serious Injury Or Illness Of A Current Servicemember For Military Family Leave (Family And Medical Leave Act) Page 2

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SECTION I: For Completion by the EMPLOYEE and/or the CURRENT SERVICEMEMBER for whom the
Employee Is Requesting Leave:
(This section must be completed first before any of the below sections can be completed by a health care provider.)
Part A: EMPLOYEE INFORMATION
Name and Address of Employer (this is the employer of the employee requesting leave to care for the current
servicemember):
____________________________________________________________________________________________
Name of Employee Requesting Leave to Care for the Current Servicemember:
____________________________________________________________________________________________
First
Middle
Last
Name of the Current Servicemember (for whom employee is requesting leave to care):
____________________________________________________________________________________________
First
Middle
Last
Relationship of Employee to the Current Servicemember:
Spouse
Parent
Son
Daughter
Next of Kin
Part B: SERVICEMEMBER INFORMATION
(1)
Is the Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves?
Yes
No
If yes, please provide the servicemember’s military branch, rank and unit currently assigned to:
_______________________________________________________________________________________
Is the servicemember assigned to a military medical treatment facility as an outpatient or to a unit established for
the purpose of providing command and control of members of the Armed Forces receiving medical care as
outpatients (such as a medical hold or warrior transition unit)?
Yes
No
If yes, please provide the name of the medical treatment facility or unit:
_________________________________________
(2)
Is the Servicemember on the Temporary Disability Retired List (TDRL)?
Yes
No
Part C: CARE TO BE PROVIDED TO THE SERVICEMEMBER
Describe the Care to Be Provided to the Current Servicemember and an Estimate of the Leave Needed to Provide the
Care:
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 2
Form WH-385 Revised May 2015

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