Form Wh-380-F Certification Of Family Member'S Serious Health Condition
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4Certification of Health Care Provider for
U.S. Department of Labor
Family Member’s Serious Health Condition
Wage and Hour Division
(Family and Medical Leave Act)
____________________________________________________________________________________________________________________________________________________________________________________________________________
OMB Control Number: 1235-0003
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
Expires: 5/31/2018
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA protections because of a need for leave to care for a covered family
member with a serious health condition to submit a medical certification issued by the health care provider of the
covered family member. Please complete Section I before giving this form to your employee. 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 C.F.R. §§ 825.306-825.308. Employers must generally maintain
records and documents relating to medical certifications, recertifications, or medical histories of 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 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies,
and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Georgia Institute of Technology/Athena Jones, Sr. Leave Specialist
Employer name and contact: _____________________________________________________________________
500 Tech Parkway NW, Atlanta GA 30332 404/894-6978 fax
__________________________________________________________________________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family
member or his/her medical provider. The FMLA permits an employer to require that you submit a timely,
complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family
member with a serious health condition. If requested by your employer, your response is required to obtain or
retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and
sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer
must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.
Your name: __________________________________________________________________________________
First
Middle
Last
Name of family member for whom you will provide care:______________________________________________
First
Middle
Last
Relationship of family member to you: _____________________________________________________________
If family member is your son or daughter, date of birth:_____________________________________________
Describe care you will provide to your family member and estimate leave needed to provide care:
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
________________________________________________ ____
____________________________________
Employee Signature
Date
Page 1
CONTINUED ON NEXT PAGE
Form WH-380-F Revised May 2015
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