Form Wh-385-V - Certification For Serious Injury Or Illness Of A Veteran For Military Caregiver Leave (Family And Medical Leave Act)

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Certification for Serious Injury
U.S. Department of Labor
or Illness of a Veteran for
Wage and Hour Division
Military Caregiver Leave
(Family and Medical Leave Act)
_____________________________________________________________________
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE EMPLOYEE
OMB Control Number: 1235-0003
Expires: 5/31/2018
Notice to the EMPLOYER
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military caregiver leave
under the FMLA leave due to a serious injury or illness of a covered veteran to submit a certification providing sufficient facts to
support the request for leave. 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 CFR 825.310. Employers must generally maintain records
and documents relating to medical certifications, recertifications, or medical histories of employees or employees’ family members,
created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance
with 29 CFR 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 CFR 1635.9, if the Genetic
Information Nondiscrimination Act applies.
SECTION I: For completion by the EMPLOYEE and/or the VETERAN for whom the employee is
requesting leave
INSTRUCTIONS to the EMPLOYEE and/or VETERAN:
Please complete Section I before having Section II completed.
The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a
request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If requested by the
employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. 2613, 2614(c)(3). Failure to
do so may result in a denial of an employee’s FMLA request. 29 CFR 825.310(f). The employer must give an employee at least 15
calendar days to return this form to the employer.
(This section must be completed before Section II 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 a veteran):
__________________________________________________________________________________________________
Name of employee requesting leave to care for a veteran:
_________________________________________________________________________________________________
First
Middle
Last
Name of veteran (for whom employee is requesting leave):
__________________________________________________________________________________________________
First
Middle
Last
Relationship of employee to veteran:
Spouse
Parent
Son
Daughter
Next of Kin
(please specify relationship):
Page 1
CONTINUED ON NEXT PAGE
Form WH-385-V Revised May 2015

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