Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act)
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4Certification of Health Care Provider for
U.S. Department of Labor
Employee’s Serious Health Condition
Wage and Hour Division
(Family and Medical Leave Act)
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT
OMB Control Number: 1235-0003
Expires: 5/31/2018
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may
require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a
medical certification issued by the employee’s health care provider. Please complete Section I before giving this form to
your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to
provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must
generally maintain records and documents relating to medical certifications, recertifications, or medical histories of
employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel
files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance
with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Employer name and contact: __________________________________________________________________
Employee’s job title: _____________________________ Regular work schedule: _______________________
Employee’s essential job functions: _____________________________________________________________
__________________________________________________________________________________________
Check if job description is attached: _____
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider.
The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to
support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response
is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a
complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your
employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name: __________________________________________________________________________________
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SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer,
fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a
condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and
examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not
be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking
leave. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in
29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29 C.F.R. §
1635.3(b). Please be sure to sign the form on the last page.
Provider’s name and business address: ___________________________________________________________
Type of practice / Medical specialty: ____________________________________________________________
Telephone: (________)____________________________ Fax:(_________)_____________________________
Page 1
Form WH-380-E Revised May 2015
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