Certification for Serious Injury or U.S. Department of Labor
Illness of Covered Servicemember - -
Employment Standards Administration
Wage and Hour Division
for Military Family Leave (Family and
Medical Leave Act)
OMB Control Number: 1215-0181
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 service
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