Fillable Certification for Serious Injury or Illness of a (City of Brockton, MA)

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Certification for Serious Injury or Illness of a (City of Brockton, MA)

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Page 1 of 4 Form WH-385-V, Revised June 2020
Certification for Serious Injury or Illness of a U.S. Department of Labor
Veteran for Military Caregiver Leave Wage and Hour Division
under the Family and Medical Leave Act
DO N
OT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003
RETURN TO THE PATIENT. Expires: 6/30/2023
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave to care for a covered
veteran with a serious illness or injury. The FMLA allows an employer to require an employee seeking FMLA leave for
this purpose to submit a medical certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the employee at
least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient certification,
his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the
WHD website at www.dol.gov/agencies/whd/fmla.
SECTION I – EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, it asks the health care
provider for the information necessary for a complete and sufficient medical certification. Recertifications are not allowed
for FMLA leave to care for a covered servicemember. Where medical certification is requested by an employer, an
employee may not be held liable for administrative delays in the issuance of military documents, despite the
employee's diligent, good-faith efforts to obtain such documents. In lieu of this form or your own certification form, you
must accept as sufficient certification of the veteran's serious injury or illness documentation indicating the veteran's
enrollment in the Department of Veterans Affairs Program of Comprehensive Assistance for Family Caregivers. 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 information, 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, and in accordance with 29 C.F.R. § 1635.9, if the Genetic
Information Nondiscrimination Act applies.
(1) Employee name: ________________________________________________________________________________
First Middle Last
(2) Employer Name: __________________________________________ Date: _______________________ (mm/dd/yyyy)
(List date certification requested)
(3) This certification must be returned by: _____________________________________________________ (mm/dd/yyyy)
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s diligent, good faith efforts.)
SECTION II - EMPLOYEE and/or VETERAN
Please complete all Parts in Section II before having the veteran’s health care provider complete Section III. The FMLA
allows 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 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. The employer must give an
employee at least 15 calendar days to return this form to the employer. 29 U.S.C. §§ 2613, 2614(c)(3).
PART A: EMPLOYEE INFORMATION
(1) Name of veteran for whom employee is requesting leave: ________________________________________________
First Middle Last
Employee Name: ____________________________________________________________________________________________
Page 2 of 4
Form WH-385-V, Revised June 2020
(2) Select your relationship to the veteran. You are the veteran’s:
Spouse P
arent Child Next of Kin
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common law
marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis in which a person assumes the obligations of a
parent to a child. An employee may take FMLA leave to care for a covered servicemember who assumed the obligations of a parent to
the employee when the employee was a child. An employee may also take FMLA leave to care for a covered servicemember for whom
the employee has assumed the obligations of a parent. No biological or legal relationship is necessary. “Next of kin” is the veteran’s
nearest blood relative, other than the spouse, parent, son, or daughter, in the following order of priority: (1) a blood relative as designated
in writing by the veteran for purposes of FMLA leave, (2) blood relatives granted legal custody of the veteran, (3) brothers and sisters,
(4) grandparents, (5) aunts and uncles, and (6) first cousins.
PART B: VETERAN INFORMATION AND CARE TO BE PROVIDED TO THE VETERAN
(3) The veteran was ( honorably / dishonorably) discharged or released from the Armed Forces, including the National
Guard or Reserves. List the date of the veteran’s discharge: _______________________________ (mm/dd/yyyy)
(4)
Please provide the veteran’s military branch, rank and unit at the time of discharge: ______________________________
_________________________________________________________________________________________________
(5) The veteran ( is / is not) receiving medical treatment, recuperation, or therapy for an injury or illness.
(6) Br
iefly describe the care you will provide to the veteran: (Check all that apply)
Assistance with basic medical, hygienic, nutritional, or safety needs Transportation
Psychological Comfort Physical Care Other: __________________________
(
7) Give your best estimate of the amount of FMLA leave needed to provide the care described: _______________________
_______________________________________________________________________________________________
(8) If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work
schedule you are able to work. From ____________________
(mm/dd/yyyy) to ____________________ (mm/dd/yyyy) I am
able to work: ______________________________
(hours per day) _________________________________ (days per week).
SECTION III - HEALTH CARE PROVIDER
Please provide your contact information, complete all Parts of this Section fully and completely, and sign the form below.
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.
Note: 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: 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 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 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 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.
Page 3 of 4 Form WH-385-V, Revised June 2020
Employee Name: ____________________________________________________________________________________________
“Need for care” includes both physical and psychological care. It includes situations where, for example, due to his or her
serious injury or illness, the veteran is not able to care for his or her own basic medical, hygienic, or nutritional needs or
safety, or needs transportation 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.
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. Information about the FMLA may be found on the WHD website
at www.dol.gov/agencies/whd/fmla.
PART A: HEALTH CARE PROVIDER INFORMATION
Health Care Provider’s Name: (Print) ___________________________________________________________________
Health Care Provider’s business address: _______________________________________________________________
Type of Practice/Medical Specialty: ____________________________________________________________________
Telephone: (___) _______________ Fax: (___) _______________ E-mail: ____________________________________
Please select the type of FMLA health care provider you are:
DOD health care provider
VA health care provider
DOD TRICARE network authorized private health care provider
DOD non-network TRICARE authorized private health care provider
Health care provider as defined in 29 CFR 825.125
PART B: MEDICAL INFORMATION
Please provide appropriate medical information of the patient as requested below. Limit your responses to the veteran’s
condition for which the employee is seeking leave. If you are unable to make certain military-related determinations
contained below, you are permitted to rely upon determinations from an authorized DOD representative, such as a DOD
Recovery Care Coordinator, or an authorized VA representative. 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).
(1) Patient’s Name: __________________________________________________________________________________
(2) List the approximate date condition started or will start: ____________________________________________ (mm/dd/yyyy)
(3) Provide your best estimate of how long the condition will last: ___________________________________________
(4) The veteran’s injury or illness: (Select as appropriate)
Was incurred in the line of duty on active duty
Existed before the beginning of the veteran’s active duty and was aggravated by
service in the line of duty on active duty
None of the above
The veteran ( is / is not) undergoing medical treatment, recuperation, or therapy for this condition. If yes, briefly
describe the medical treatment, recuperation, or therapy: __________________________________________________
_______________________________________________________________________________________________
Employee Name: ____________________________________________________________________________________________
Page 4 of 4
Form WH-385-V, Revised June 2020
(5) The veteran’s medical condition is: (Select as appropriate)
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 not able 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. 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 29 C.F.R. § 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.
Part C: Amount of Leave Needed
For the medical condition checked in Part B, complete all that apply. Some 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.
(1) Due to the condition, the veteran will need care for a continuous period of time, including any time for treatment and
recovery. Provide your best estimate of the beginning date _______________ (mm/dd/yyyy) and end date _____________
(mm/dd/yyyy) for this period of time.
(2
) Due to the condition, it is medically necessary for the veteran to attend planned medical treatment appointments (scheduled
medical visits). Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery
_________________________________________________________________________ (e.g. 3 days/week)
(3
) Due to the condition, it is medically necessary for the veteran to receive care on an intermittent basis (periodically), such
as the care needed because of episodic flare-ups of the condition or assisting with the veteran’s recovery. Provide your best
estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.
Over the next 6 months, intermittent care is estimated to occur _____________ times per ( day / week / month)
and are likely to last approximately _____________ ( hours / days) per episode.
Sig
nature of
Health Care Provider_________________________________________________ Date _______________ (mm/dd/yyyy)
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 15 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 Avenue, NW, Washington, DC 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
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Certification for Serious Injury or Illness of a (City of Brockton, MA)

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Completed 31 January 2021

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