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Certification of Health Care Provider for

Employee's Serious Health Condition

(Family and Medical Leave Act)

U.S. Department of Labor

iWHD

Wage and Hour Division

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OMB Control Number: 1235-0003

Ex ires: 2/28/2015

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 due to a serious health condition to

submit a medical certification issued by the employee's health care provider. 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 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)(l), if the Americans with Disabilities

Act applies.

Employer name and c o n t a c t : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Employee's job title: --------,.--------Regular work s c h e d u l e : - - - - - - - - - -

Employee's essential job f u n c t i o n s : - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Check if job description is attached: _ _

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INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your 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 due to your own serious health condition. If requested by your

employer, your response is required to obtain or retain the benefit ofFMLA 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. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R.

§ 825.305(b).

Your name:

-----------~~---------------------------

First

Middle

Last

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INSTRUCTIONS to the HEAL

CARE PROVIDER: Your patient has requested leave under the FMLA.

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 coverage. Limit your responses to the

condition for which the employee is seeking leave. Please be sure to sign the form on the last page.

Provider's name and business address:

----------------------------------

Type of practice

Medical specialty: - - - - - - - - - - - - - - - - - - - - - - - - - -

Page I

CONTINUED ON NEXT PAGE

Form WH-380-E Revised January 2009

Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act)

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