Fillable 385-certification-serious-injury-illness-current-servicemember BILLING CODE 4510-27-P

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385-certification-serious-injury-illness-current-servicemember BILLING CODE 4510-27-P

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Page 1 CONTINUED ON NEXT PAGE Form WH-385 Revised February 2013
Certification for Serious Injury or U.S. Department of Labor
Illness of a Current
Wage and Hour Division
Servicemember - -for Military Family Leave
(Family and Medical Leave Act)
OMB Control Number: 1235-0003
Expires: 2/28/2015
Notice to the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may
require an employee seeking FMLA leave due to a serious injury or illness of a current servicemember to submit a
certification providing sufficient facts to support the request for leave. 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 CFR 825.310. Employers must generally maintain records and documents relating to medical
certifications, recertifications, or medical histories of employees or 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
CFR 1630.14(c)(1), if the Americans with Disabilities Act applies.
SECTION I: For Completion by the EMPLOYEE and/or the CURRENT SERVICEMEMBER for whom the
Employee Is Requesting Leave
INSTRUCTIONS to the EMPLOYEE or CURRENT SERVICEMEMBER: Please complete Section I before having
Section II completed. The FMLA permits an employer to require that an employee submit a timely, complete, and
sufficient certification to support a request for FMLA leave due to a serious injury or illness of a servicemember. If
requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C.
2613, 2614(c)(3). Failure to do so may result in a denial of an employee’s FMLA request. 29 CFR 825.310(f). The
employer must give an employee at least 15 calendar days to return this form to the employer.
SECTION II: For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH CARE
PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of Veterans Affairs
(“VA”) health care provider; (2) a DOD TRICARE network authorized private health care provider; (3) a DOD
non-network TRICARE authorized private health care provider; or (4) a health care provider as defined in 29
CFR 825.125
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed on Page 2 has requested leave under the
FMLA to care for a family member who is a current member of the Regular Armed Forces, the National Guard, or the
Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise
on the temporary disability retired list for a serious injury or illness. For purposes of FMLA leave, a serious injury or
illness is one that was incurred in the line of duty on active duty in the Armed Forces or that existed before the beginning
of the member’s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces that
may render the servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating.
A complete and sufficient certification to support a request for FMLA leave due to a current servicemember’s serious
injury or illness includes written documentation confirming that the servicemember’s injury or illness was incurred in the
line of duty on active duty or if not, that the current servicemember’s injury or illness existed before the beginning of the
servicemember’s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces, and
that the current servicemember is undergoing treatment for such injury or illness by a health care provider listed above.
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 servicemember’s condition for which the
employee is seeking leave.
Page 2 CONTINUED ON NEXT PAGE Form WH-385 Revised February 2013
SECTION I: For Completion by the EMPLOYEE and/or the CURRENT SERVICEMEMBER for whom the
Employee Is Requesting Leave:
(This section must be completed first before any of the below sections can be completed by a health care provider.)
Part A: EMPLOYEE INFORMATION
Name and Address of Employer (this is the employer of the employee requesting leave to care for the current
servicemember):
____________________________________________________________________________________________
Name of Employee Requesting Leave to Care for the Current Servicemember:
____________________________________________________________________________________________
First Middle Last
Name of the Current Servicemember (for whom employee is requesting leave to care):
____________________________________________________________________________________________
First Middle Last
Relationship of Employee to the Current Servicemember:
Spouse
Parent Son Daughter Next of Kin
Part B: SERVICEMEMBER INFORMATION
(1) Is the Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves?
Yes
No
If yes, please provide the servicemember’s military branch, rank and unit currently assigned to:
_______________________________________________________________________________________
Is the servicemember assigned to a military medical treatment facility as an outpatient or to a unit established for
the purpose of providing command and control of members of the Armed Forces receiving medical care as
outpatients (such as a medical hold or warrior transition unit)?
Yes
No
If yes, please provide the name of the medical treatment facility or unit:
_________________________________________
(2) Is the Servicemember on the Temporary Disability Retired List (TDRL)?
Yes
No
Part C: CARE TO BE PROVIDED TO THE SERVICEMEMBER
Describe the Care to Be Provided to the Current Servicemember and an Estimate of the Leave Needed to Provide the
Care:
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 3 CONTINUED ON NEXT PAGE Form WH-385 Revised February 2013
SECTION II: For Completion by a United States Department of Defense (“DOD”) Health Care Provider or a
Health Care Provider who is either: (1) a United States Department of Veterans Affairs (“VA”) health care
provider; (2) a DOD TRICARE network authorized private health care provider; (3) a DOD non-network
TRICARE authorized private health care provider; or (4) a health care provider as defined in 29 CFR
825.125. If you are unable to make certain of the military-related determinations contained below in Part B, you
are permitted to rely upon determinations from an authorized DOD representative (such as a DOD recovery care
coordinator).
(Please ensure that Section I above has been completed before completing this section. Please be sure to sign the form on
the last page.)
Part A: HEALTH CARE PROVIDER INFORMATION
Health Care Provider’s Name and Business Address:
____________________________________________________________________________________________
Type of Practice/Medical Specialty: _______________________________________________________________
Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD TRICARE
network authorized private health care provider; (4) a DOD non-network TRICARE authorized private health care
provider, or (5) a health care provider as defined in 29 CFR 825.125:
_____________________________________________________________________
Telephone: ( ) _____________ Fax: ( ) ______________ Email: ___________________________________
PART B: MEDICAL STATUS
(1) The current Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):
(VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently endangered.
Family members are requested at bedside immediately. (Please note this is an internal DOD casualty assistance
designation used by DOD healthcare providers.)
(SI) Seriously Ill/Injured – Illness/injury is of such severity that there is cause for immediate concern, but
there is no imminent danger to life. Family members are requested at bedside. (Please note this is an internal
DOD casualty assistance designation used by DOD healthcare providers.)
OTHER Ill/Injured – a serious injury or illness that may render the servicemember medically unfit to
perform the duties of the member’s office, grade, rank, or rating.
NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take leave to
care for a covered family member with a “serious health condition” under § 825.113 of the FMLA. If such leave
is requested, you may be required to complete DOL FORM WH-380-F or an employer-provided form seeking the
same information.)
(2) Is the current Servicemember being treated for a condition which was incurred or aggravated by service in the line
of duty on active duty in the Armed Forces? Yes
No
(3) Approximate date condition commenced: _______________________________________________
(4) Probable duration of condition and/or need for care: ______________________________________
Page 4 Form WH-385 Revised February 2013
(5) Is the servicemember undergoing medical treatment, recuperation, or therapy for this condition? Yes
No
If yes, please describe medical treatment, recuperation or therapy:
_________________________________________________________________________________________
PART C: SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1) Will the servicemember need care for a single continuous period of time, including any time for treatment and
recovery? Yes
No
If yes, estimate the beginning and ending dates for this period of time: ________________________________
(2) Will the servicemember require periodic follow-up treatment appointments? Yes
No
If yes, estimate the treatment schedule: __________________________________________
(3) Is there a medical necessity for the servicemember to have periodic care for these follow-up treatment
appointments? Yes
No
(4) Is there a medical necessity for the servicemember to have periodic care for other than scheduled follow-up
treatment appointments (e.g., episodic flare-ups of medical condition)?
Yes
No
If yes, please estimate the frequency and duration of the periodic care:
_________________________________________________________________________________________
_________________________________________________________________________________________
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, in accordance with 29 U.S.C. 2616; 29
CFR 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 AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION;
RETURN IT TO THE PATIENT.
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