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Form Wh-385 - Certification For Serious Injury Or Illness Of A Current Servicemember For Military Family Leave (Family And Medical Leave Act) Page 4



(5)

Is the servicemember undergoing medical treatment, recuperation, or therapy for this condition? Yes

If yes, please describe medical treatment, recuperation or therapy:

_________________________________________________________________________________________

PART C: SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER

(1)

Will the servicemember need care for a single continuous period of time, including any time for treatment and



recovery? Yes

If yes, estimate the beginning and ending dates for this period of time: ________________________________



(2)

Will the servicemember require periodic follow-up treatment appointments? Yes

If yes, estimate the treatment schedule: __________________________________________

(3)

Is there a medical necessity for the servicemember to have periodic care for these follow-up treatment



appointments? Yes

(4)

Is there a medical necessity for the servicemember to have periodic care for other than scheduled follow-up

treatment appointments (e.g., episodic flare-ups of medical condition)?



Yes

If yes, please estimate the frequency and duration of the periodic care:

_________________________________________________________________________________________

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, in accordance with 29 U.S.C. 2616; 29

CFR 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 AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION;

RETURN IT TO THE PATIENT.

Page 4

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 4

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