Form WH-380-F: Certification of Health Care Provider for Family Member's Serious Health Condition
Optional DOL form for medical certification when an employee needs FMLA leave to care for a spouse, child or parent with a serious health condition.
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Instructions for filling out Form WH-380-F: Certification of Health Care Provider for Family Member'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 caring for a seriously ill family member.
- HR teams processing caregiver leave.
- Health care providers of the family member.
What you will need before starting
Before filling out the interactive form, prepare the following details and documents:
Step-by-step filling process
- Employer completes Section I: Enter details and the due date.
- Employee completes Section II: Describe the care you'll provide.
- Provider completes Section III: Medical facts and estimates.
- Return to employer: Generally within 15 calendar days.
Frequently Asked Questions (FAQ)
Who counts as a family member?
Under FMLA: spouse, child, or parent (not in-laws).
Can I take intermittent leave?
Yes, if medically necessary, as certified by the provider.
Is this form mandatory?
No, but employers may require equivalent certification.
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