Form WH-380-E: Certification of Health Care Provider for Employee's Serious Health Condition

Optional DOL form an employer can use to request medical certification for FMLA leave due to the employee's own serious health condition. Completed partly by the employer and partly by the employee's health care provider.

Rev. June 2020

Source: U.S. Department of Labor, Wage and Hour Division

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Instructions for filling out Form WH-380-E: Certification of Health Care Provider for Employee's Serious Health Condition

This template is used for official filing and documentation. Below are detailed instructions for completing, requirement details, and submission rules.

Who needs to fill out this document?

This form is designed for use by legal entities, individuals, or authorized representatives in the following cases:

Employees requesting FMLA leave for their own health condition.
HR teams administering FMLA requests.
Health care providers certifying a condition.

What you will need before starting

Before filling out the interactive form, prepare the following details and documents:

1. Employer sectionEmployee's job title, schedule and essential job functions.

2. Provider informationName, type of practice and contact details.

3. Medical factsDates of condition, treatment and whether it meets FMLA criteria.

4. Amount of leave neededContinuous, intermittent or reduced schedule estimates.

Step-by-step filling process

Employer completes Section I: Provide job information and the return deadline.
Employee takes form to provider: The employee gives the form to their health care provider.
Provider completes Section III: Medical facts and estimated leave needed.
Return to employer: Generally within 15 calendar days of the request.

Frequently Asked Questions (FAQ)

Do I have to use this exact form?

No. It's optional; employers may use another form with the same information.

Does the employer get my diagnosis?

The form asks for medical facts sufficient to support the leave, not necessarily a diagnosis.

Is medical information kept confidential?

Yes. Employers must keep it in separate confidential medical files.

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