Fillable Certification for Serious Injury U.S. Department of Labor

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Certification for Serious Injury U.S. Department of Labor

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Certification for Serious Injury U.S. Department of Labor
or Illness of a Veteran for Wage and Hour Division
Military Caregiver Leave
(Family and Medical Leave Act)
_____________________________________________________________________
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE EMPLOYEE OMB Control Number: 1235-0003
Expires: 5/31/2018
Notice to the EMPLOYER
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military caregiver leave
under the FMLA leave due to a serious injury or illness of a covered veteran 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, and in accordance with 29 CFR 1635.9, if the Genetic
Information Nondiscrimination Act applies.
SECTION I: For completion by the EMPLOYEE and/or the VETERAN for whom the employee is
requesting leave
INSTRUCTIONS to the EMPLOYEE and/or VETERAN:
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 military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. 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.
(This section must be completed before Section II 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 a veteran):
__________________________________________________________________________________________________
Name of employee requesting leave to care for a veteran:
_________________________________________________________________________________________________
First Middle Last
Name of veteran (for whom employee is requesting leave):
__________________________________________________________________________________________________
First Middle Last
Relationship of employee to veteran:
Spouse
Parent Son Daughter Next of Kin (please specify relationship):
Page 1 CONTINUED ON NEXT PAGE Form WH-385-V Revised May 2015
Part B: VETERAN INFORMATION
(1) Date of the veteran’s discharge:
_____________________________________________________________________________________
(2) Was the veteran dishonorably discharged or released from the Armed Forces (including the National Guard
or Reserves)? Yes
No
(3) Please provide the veteran’s military branch, rank and unit at the time of discharge:
___________________________________________________________________________________________
(4) Is the veteran receiving medical treatment, recuperation, or therapy for an injury or illness?
Yes
No
Part C: CARE TO BE PROVIDED TO THE VETERAN
Describe the care to be provided to the veteran and an estimate of the leave needed to provide the care:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Page 2 CONTINUED ON NEXT PAGE Form WH-385-V Revised May 2015
SECTION II: For completion by: (1) a United States Department of Defense (“DOD”) health care provider; (2) a
United States Department of Veterans Affairs (“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.
INSTRUCTIONS to the HEALTH CARE PROVIDER:
The employee named in Section I has requested leave under the
military caregiver leave provision of the FMLA to care for a family member who is a veteran. For purposes of FMLA military
caregiver leave, a serious injury or illness means an injury or illness incurred by the servicemember in the line of duty on active duty
in the Armed Forces (or that 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 manifested itself before or after the servicemember became a veteran, and is:
(i) a continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member of
the Armed Forces and rendered the servicemember unable to perform the duties of the servicemember’s office, grade, rank,
or rating; or
(ii) a physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs Service
Related Disability Rating (VASRD) of 50 percent or greater, and such VASRD rating is based, in whole or in part, on the
condition precipitating the need for military caregiver leave; or
(iii) a physical or mental condition that substantially impairs the covered veteran’s ability to secure or follow a substantially
gainful occupation by reason of a disability or disabilities related to military service, or would do so absent treatment; or
(iv) an injury, including a psychological injury, on the basis of which the covered veteran has been enrolled in the
Department of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
A complete and sufficient certification to support a request for FMLA military caregiver leave due to a covered veteran’s serious
injury or illness includes written documentation confirming that the veteran’s injury or illness was incurred in the line of duty on
active duty or existed before the beginning of the veteran’s active duty and was aggravated by service in the line of duty on active
duty, and that the veteran is undergoing treatment, recuperation, or therapy 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 military caregiver leave coverage. Limit your responses to the veteran’s condition for which the employee is
seeking leave. Do not provide information about genetic tests, as defined in 29 CFR 1635.3(f), or genetic services, as defined in 29
CFR 1635.3(e).
(Please ensure that Section I has been completed before completing this section. Please be sure to sign the form on the
last page and return this form to the employee requesting leave (See Section I, Part A above).
DO NOT SEND THE
COMPLETED FORM TO THE WAGE AND HOUR DIVISION.
)
Part A: HEALTH CARE PROVIDER INFORMATION
Health care provider’s name and business address:
__________________________________________________________________________________________________
Telephone: ( ) _______________ Fax: ( ) ________________ Email: ______________________________________
Type of Practice/Medical Specialty: ____________________________________________________________________
Please indicate if you are:
a DOD health care provider
a VA health care provider
a DOD TRICARE network authorized private health care provider
a DOD non-network TRICARE authorized private health care provider
other health care provider
Page 3 CONTINUED ON NEXT PAGE Form WH-385-V Revised May 2015
PART B: MEDICAL STATUS
N
ote: If you are unable to make certain of the military-related determinations contained in Part B, you are permitted to
rely upon determinations from an authorized DOD representative (such as, DOD Recovery Care Coordinator) or an
authorized VA representative.
(1
) The Veteran’s medical condition is:
A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a
member of the Armed Forces and rendered the servicemember unable to perform the duties of the
servicemember’s office, grade, rank, or rating.
A physical or mental condition for which the covered veteran has received a U.S. Department of Veterans
Affairs Service Related Disability Rating (VASRD) of 50% or higher, and such VASRD rating is based, in
whole or in part, on the condition precipitating the need for military caregiver leave.
A physical or mental condition that substantially impairs the covered veteran’s ability to secure or follow a
substantially gainful occupation by reason of a disability or disabilities related to military service, or would do
so absent treatment.
An injury, including a psychological injury, on the basis of which the covered veteran is enrolled in the Department
of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
None of the above.
(2
) Is the veteran 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: ________________________________________________
(5
) Is the veteran undergoing medical treatment, recuperation, or therapy for this condition? Yes
No
I
f yes, please describe medical treatment, recuperation or therapy:
_________
____________________________________________________________________________________
PART C: VETERAN’S NEED FOR CARE BY FAMILY MEMBER
“N
eed for care” encompasses both physical and psychological care. It includes situations where, for example, due to his
or her serious injury or illness, the veteran is unable to care for his or her own basic medical, hygienic, or nutritional needs
or safety, or is unable to transport him or herself to the doctor. It also includes providing psychological comfort and
reassurance which would be beneficial to the veteran who is receiving inpatient or home care.
(
1) Will the veteran 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 veteran require periodic follow-up treatment appointments? Yes
No
I
f yes, estimate the treatment schedule: _____________________________________________________________
Page 4 CONTINUED ON NEXT PAGE Form WH-385-V Revised May 2015
(3
) Is there a medical necessity for the veteran to have periodic care for these follow-up treatment appointments?
Yes
No
(4) Is there a medical necessity for the veteran to have periodic care for other than scheduled follow-up treatment
appointments (e.g., episodic flare-ups of medical condition)? Yes
No
I
f yes, please estimate the frequency and duration of the periodic care:
_________
____________________________________________________________________________________
_________
____________________________________________________________________________________
S
ignature 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 Ave., NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION;
RETURN IT TO THE EMPLOYEE REQUESTING LEAVE (As shown in Section I, Part “A” above).
Page 5 Form WH-385-V Revised May 2015
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Certification for Serious Injury U.S. Department of Labor

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