Fillable Certification For Family Member WH 380 F (Goucher College)

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Certification For Family Member WH 380 F (Goucher College)

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____________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
________________________________________________ ____ ____________________________________
Certification of Health Care Provider for
U.S. Department of Labor
Family Member’s Serious Health Condition
(Family and Medical Leave Act)
Wage and Hour Division
OMB Control Number: 1235-0003
Expires: 8/31/2021
SECTION I: For Completion by the EMPLOYER
INSTRUCTIO
NS 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.
Employer name and contact: _______
______________________________________________________________
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 me
dical 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 bir
t
h:____
___
___
_
____
___
___
_
____
___
___
_
____
___
___
_
_
Describe care
y
ou 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
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
Goucher College (Contact: Mallory Kola, p: 410-337-6343 or f: 410-337-6236)
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under
the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. 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 patient needs leave. Do not provide information
about genetic tests, as defined in 29 C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e).
Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last
page.
Provider’s name and business address:______________________________________________________________
Type of practice / Medical specialty: ______________________________________________________________
Telephone: (________)____________________________ Fax:(_________)_______________________________
PART A: MEDICAL FACTS
1. Approximate date condition commenced: ______
___________________________________________________
Probable duration of condition: _________________________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospi
ce, or residential
m
e
dical care facility
?
___
No ___Yes. If so, dates of admission: _______________________________________________________
Date(s) you treated the patient for condition: ______________________________________________________
Was
medication, other than over-the-counter medication, prescribed?
___
No
___Yes.
Will the patient need to
have treat
m
ent visits at least twice per year due to the condition? ___No ____ Yes
Was the patie
nt referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
____
No ____Yes. If so, state the nature of such treatme
nts and expected duration of treatment:
2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ______________________
3. Describe other relevant medical fa
cts, if any, related to the condition for which the patient needs care (s
uch
medical facts
may include sy
mptoms, diagnosis, or any regimen of continuing treatm
ent such as the use of
specializ
ed equipm
ent):
Page 2 CONTINUED ON NEXT PAGE
Form WH-380-F Revised May 201
5
__________________________________________________________________________________________
PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need
for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or
transportation needs, or the provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and
recovery
? ___No
___
Yes.
Estim
ate the beginning and ending dates for the perio
d
of incapacity
:
__
___
___
_
__________________________
During this time, will the patient need care? __ No __ Yes.
Explain the c
are needed by the patient and why such care is medically necessary:
5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes.
Estim
ate treatment schedule, if any, including the dates of any scheduled appoi
ntments and the time required for
each appointment, includi
ng any recovery
period:
Explain the c
are needed by the patient, and why such care is medically necessary: ________
________________
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? __
No
__
Yes.
Estim
a
te the
hours the pati
ent needs care on an inter
m
ittent basis, if any
:
________ hour(s) per day; ________ days per week from _________________ through __________________
Explain the c
are needed by the patient, and why such care is medically necessary:
Page 3 CONTINUED ON NEXT PAGE Form WH-380-F Revised May 2015
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________ ____________________________________________
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily
activities?
____No ____Yes
.
Based upon t
he patient’s medical history
and your knowledge of t
h
e medical co
ndition, estimate the frequency
of
flare-ups and the duration
o
f
related incapacity
that the patient may have over the next 6 months (e.g., 1 epis
ode
every
3 months lasting 1-2 days
):
Frequency
: _____ times per _____ week(s) _____
month(s)
Duration: _____
hours or ___ day(s) per
episode
Does the patient need care during these flare-ups? ____
No ____ Y
es.
Explain the c
are needed by the patient, and why such care is medically necessary
: ________
________________
____ ___
____ ___
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
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.F.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 NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
Page 4 Form WH-380-F Revised May 2015
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Certification For Family Member WH 380 F (Goucher College)

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Completed 22 July 2020

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