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)
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT
OMB Control Number: 1235-0003
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, 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 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
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.
lete 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. 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).
Page 1 Form WH-385 Revised May 2015