Looking for a Form Wh-380-e Templates? Download it for free!

Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 2

~~IJ:i!I;:~;~~~QA,L.·F;AQT~

1. Approximate date condition c o m m e n c e d : - - - - - - - - - - - - - - - - - - - - - - - - -

Probable duration of condition:

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

Mark below as applicable:

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?

_No _Yes. If so, dates of admission:

Date(s) you treated the patient for condition:

Will the patient need to have treatment visits at least twice per year due to the condition? _No

Yes.

Was medication, other than over-the-counter medication, prescribed? _No _Yes.

Was the patient referred to other health care provider( s) for evaluation or treatment

physical therapist)?

__ No __ yes. If so, state the nature of such treatments and expected duration of treatment:

2. Is the medical condition pregnancy? _No _Yes. If so, expected delivery date: _ _ _ _ _ _ _ _ _

3. Use the information provided by the employer in Section I to answer this question. If the employer fails to

provide a list of the employee's essential ftmctions or a job description, answer these questions based upon

the employee's own description of his/her job functions.

Is the employee unable to perform any of his/her job ftmctions due to the condition:

Yes.

If so, identify the job functions the employee is unable to perform:

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave

(such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use

of specialized equipment):

Page 2

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) Page 2