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SECTION II: For Completion by a United States Department of Defense (“DOD”) Health Care Provider or a

Health Care Provider who is either: (1) a United States Department of Veterans Affairs (“VA”) health care

provider; (2) a DOD TRICARE network authorized private health care provider; (3) a DOD non-network

a health care provider as defined in 29 CFR

TRICARE authorized private health care provider; or (4)

825.125

. If you are unable to make certain of the military-related determinations contained below in Part B, you

are permitted to rely upon determinations from an authorized DOD representative (such as a DOD recovery care

coordinator).

(Please ensure that Section I above has been completed before completing this section. Please be sure to sign the form on

the last page.)

Part A: HEALTH CARE PROVIDER INFORMATION

Health Care Provider’s Name and Business Address:

____________________________________________________________________________________________

Type of Practice/Medical Specialty: _______________________________________________________________

Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD TRICARE

network authorized private health care provider; (4) a DOD non-network TRICARE authorized private health care

provider, or (5) a health care provider as defined in 29 CFR 825.125:

_____________________________________________________________________

Telephone: (

) _____________ Fax: (

) ______________ Email: ___________________________________

PART B: MEDICAL STATUS

(1) The current Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):



(VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently endangered.

Family members are requested at bedside immediately. (Please note this is an internal DOD casualty assistance

designation used by DOD healthcare providers.)



(SI) Seriously Ill/Injured – Illness/injury is of such severity that there is cause for immediate concern, but

there is no imminent danger to life. Family members are requested at bedside. (Please note this is an internal

DOD casualty assistance designation used by DOD healthcare providers.)



OTHER Ill/Injured – a serious injury or illness that may render the servicemember medically unfit to

perform the duties of the member’s office, grade, rank, or rating.



NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take leave to

care for a covered family member with a “serious health condition” under § 825.113 of the FMLA. If such leave

is requested, you may be required to complete DOL FORM WH-380-F or an employer-provided form seeking the

same information.)

(2)

Is the current Servicemember being treated for a condition which was incurred or aggravated by service in the line



of duty on active duty in the Armed Forces? Yes

(3)

Approximate date condition commenced: _______________________________________________

(4)

Probable duration of condition and/or need for care: ______________________________________

Page 3

Form WH-385 Revised May 2015

Form Wh-385 - Certification For Serious Injury Or Illness Of A Current Servicemember For Military Family Leave (Family And Medical Leave Act) Page 3

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