Form Wh-385-V - Certification For Serious Injury Or Illness Of A Veteran For Military Caregiver Leave (Family And Medical Leave Act) Page 4
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5PART B: MEDICAL STATUS
Note: If you are unable to make certain of the military-related determinations contained in Part B, you are permitted to
rely upon determinations from an authorized DOD representative (such as, DOD Recovery Care Coordinator) or an
authorized VA representative.
(1)
The Veteran’s medical condition is:
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.
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% or higher, and such VASRD rating is based, in
whole or in part, on the condition precipitating the need for military caregiver leave.
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.
veteran is enrolled in the Department
An injury, including a psychological injury, on the basis of which the covered
of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
None of the above.
(2)
Is the veteran 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
No
(3)
Approximate date condition commenced: _________________________________________________________
(4)
Probable duration of condition and/or need for care: ________________________________________________
(5)
Is the veteran undergoing medical treatment, recuperation, or therapy for this condition?
Yes
No
If yes, please describe medical treatment, recuperation or therapy:
_____________________________________________________________________________________________
PART C: VETERAN’S NEED FOR CARE BY FAMILY MEMBER
“Need for care” encompasses both physical and psychological care. It includes situations where, for example, due to his
or her serious injury or illness, the veteran is unable to care for his or her own basic medical, hygienic, or nutritional needs
or safety, or is unable to transport him or herself to the doctor. It also includes providing psychological comfort and
reassurance which would be beneficial to the veteran who is receiving inpatient or home care.
(1)
Will the veteran need care for a single continuous period of time, including any time for treatment and recovery?
Yes
No
If yes, estimate the beginning and ending dates for this period of time: ____________________________________
(2)
Will the veteran require periodic follow-up treatment appointments? Yes
No
If yes, estimate the treatment schedule: _____________________________________________________________
Page 4
CONTINUED ON NEXT PAGE
Form WH-385-V Revised May 2015
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