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Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 4

Signature of Health Care Provider

Date

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C.

2616; 29

C.P.R.

825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB

control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this

collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining

the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden

estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the

Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC

20210. DO NOTSENDCOMPLETEDFORMTO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

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Form WH-380-E Revised January2009

Form Wh-380-E - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) Page 4