Certification for Serious Injury or
Illness of Covered Servicemember - -
for Military Family Leave (Family and
Medical Leave Act)
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
____________________________________________________________________________________________________________________________________________________________________________________________________________
OMB Control Number: 1215-0181
Expires: 12/31/2011
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 covered 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 C.F.R. § 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 C.F.R. § 1630.14(c)(1), if the Americans with
Disabilities Act applies.
SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom
the Employee Is Requesting Leave INSTRUCTIONS to the EMPLOYEE or COVERED
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 covered 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 C.F.R. § 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; or (3) a DOD non-network TRICARE authorized private health care provider 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 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 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 covered servicemember’s
serious injury or illness includes written documentation confirming that the covered servicemember’s injury or
illness was incurred in the line of duty on active duty and that the covered 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 condition for which the employee is seeking leave.
Page 1 CONTINUED ON NEXT PAGE Form WH-385 January 2009
Certification for Serious Injury or Illness
of Covered Servicemember - - for
Military Family Leave (Family and
Medical Leave Act)
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
SECTION I: For Completion by the EMPLOYEE and/or the COVERED 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 covered
servicemember):
____________________________________________________________________________________________
Name of Employee Requesting Leave to Care for Covered Servicemember:
____________________________________________________________________________________________
First Middle Last
Name of Covered Servicemember (for whom employee is requesting leave to care):
____________________________________________________________________________________________
First Middle Last
Relationship of Employee to Covered Servicemember Requesting Leave to Care:
Spouse Parent Son Daughter Next of Kin
Part B: COVERED SERVICEMEMBER INFORMATION
(1) Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or
Reserves? ___Yes ____No
If yes, please provide the covered servicemember’s military branch, rank and unit currently assigned to:
_______________________________________________________________________________________
Is the covered 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 Covered Servicemember on the Temporary Disability Retired List (TDRL)? ____Yes ____No
Part C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER
Describe the Care to Be Provided to the Covered Servicemember and an Estimate of the Leave Needed to Provide
the Care:
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 2 CONTINUED ON NEXT PAGE Form WH-385 January 2009
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; or (3) a DOD non-
network TRICARE authorized private health care provider. 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; or (4) a DOD non-network TRICARE authorized
private health care provider: _____________________________________________________________________
Telephone: ( ) _____________ Fax: ( ) ______________ Email: ___________________________________
PART B: MEDICAL STATUS
(1) Covered 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 or an employer-provided
form seeking the same information.)
(2) Was the condition for which the Covered Service member is being treated incurred in 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 covered servicemember undergoing medical treatment, recuperation, or therapy? ____Yes ___No. If
yes, please describe medical treatment, recuperation or therapy:
_________________________________________________________________________________________
Page 3 CONTINUED ON NEXT PAGE Form WH-385 January 2009
PART C: COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1) Will the covered 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 covered servicemember require periodic follow-up treatment appointments?
___ Yes ___ No If yes, estimate the treatment schedule: __________________________________________
(3) Is there a medical necessity for the covered servicemember to have periodic care for these follow-up treatment
appointments? ____Yes _____No
(4) Is there a medical necessity for the covered 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 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 AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM
TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE PATIENT.
Page 4 Form WH-385 January 2009
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