Form Wh-385-V - Certification For Serious Injury Or Illness Of A Veteran For Military Caregiver Leave (Family And Medical Leave Act) Page 3
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5SECTION II: For completion by: (1) a United States Department of Defense (“DOD”) health care provider; (2) a
United States Department of Veterans Affairs (“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.
INSTRUCTIONS to the HEALTH CARE PROVIDER:
The employee named in Section I has requested leave under the
military caregiver leave provision of the FMLA to care for a family member who is a veteran. For purposes of FMLA military
caregiver leave, a serious injury or illness means an injury or illness incurred by the servicemember in the line of duty on active duty
in the Armed Forces (or that existed before the beginning of the servicemember’s active duty and was aggravated by service in the line
of duty on active duty in the Armed Forces) and manifested itself before or after the servicemember became a veteran, and is:
(i) a continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member of
the Armed Forces and rendered the servicemember unable to perform the duties of the servicemember’s office, grade, rank,
or rating; or
(ii) a physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs Service
Related Disability Rating (VASRD) of 50 percent or greater, and such VASRD rating is based, in whole or in part, on the
condition precipitating the need for military caregiver leave; or
(iii) a physical or mental condition that substantially impairs the covered veteran’s ability to secure or follow a substantially
gainful occupation by reason of a disability or disabilities related to military service, or would do so absent treatment; or
(iv) an injury, including a psychological injury, on the basis of which the covered veteran has been enrolled in the
Department of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
A complete and sufficient certification to support a request for FMLA military caregiver leave due to a covered veteran’s serious
injury or illness includes written documentation confirming that the veteran’s injury or illness was incurred in the line of duty on
active duty or existed before the beginning of the veteran’s active duty and was aggravated by service in the line of duty on active
duty, and that the veteran is undergoing treatment, recuperation, or therapy for such injury or illness by a health care provider listed
above. 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 military caregiver leave coverage. Limit your responses to the veteran’s condition for which the employee is
seeking leave. Do not provide information about genetic tests, as defined in 29 CFR 1635.3(f), or genetic services, as defined in 29
CFR 1635.3(e).
(Please ensure that Section I has been completed before completing this section. Please be sure to sign the form on the
last page and return this form to the employee requesting leave (See Section I, Part A above).
DO NOT SEND THE
)
COMPLETED FORM TO THE WAGE AND HOUR DIVISION.
Part A: HEALTH CARE PROVIDER INFORMATION
Health care provider’s name and business address:
__________________________________________________________________________________________________
Telephone: (
) _______________ Fax: (
) ________________ Email: ______________________________________
Type of Practice/Medical Specialty: ____________________________________________________________________
Please indicate if you are:
a DOD health care provider
a VA health care provider
a DOD TRICARE network authorized private health care provider
a DOD non-network TRICARE authorized private health care provider
other health care provider
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CONTINUED ON NEXT PAGE
Form WH-385-V Revised May 2015
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