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Family Military

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  • 29 check-boxes
  • 125 other fields

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Revised 12/2019
Packet Updated 12/2019
YOUR NEXT STEPS
FAMILY MILITARY LEAVE OF ABSENCE
(Qualifying Exigency or Care for Covered Service member/Veteran)
1. Apply for time off and job protection under the Family and Medical Leave Act
(“FMLA”) if you have completed one year of service and have worked at least
1,250 hours during the 12 months before the start of your leave. Please note that
some states have their own leave laws with different eligibility requirements and
benefits. Contact HR XPRESS with any questions about your potential eligibility
and benefits under a state leave law.
•
Read the attached Employee Rights and Responsibilities under the Family
and Medical Leave Act for details.
2. Complete the appropriate attached certification based on your need:
• Certification of Qualifying Exigency For Military Family Leave (WH-384) - to be
completed by the associate; please also attach military orders
• Certification for Serious Injury or Illness of a Current Service member for
Military Family Leave (WH-385) – this form also needs to be completed by the
covered family member’s health care provider
• Certification for Serious Injury or Illness of a Veteran for Military Caregiver
Leave (WH-385V) - this form also needs to be completed by the covered family
member’s health care provider
3. Email the completed form two weeks before the start of your leave, or as soon as
possible to loaforms@tjx.com. You or the health care provide can submit the
form, but you must ensure that HR XPRESS receives it.
Notes:
• Once HR XPRESS reviews all completed documents, we will mail you a Leave
Status Update informing you of the time off granted, as well as a Designation Notice
regarding FMLA.
•
Paid Family Leave benefits may also be available to associates in Rhode Island.
•
Visit www.Ripaidleave.net for additional information.
EMPLOYEE RIGHTS
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period
for the following reasons:
• The birth of a child or placement of a child for adoption or foster care;
• To bond with a child (leave must be taken within 1 year of the child’s birth or placement);
• To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;
• For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;
• For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,
child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks
of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.
An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees
may take leave intermittently or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee
substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.
While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.
Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with
equivalent pay, benets, and other employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave,
opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.
An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must:
• Have worked for the employer for at least 12 months;
• Have at least 1,250 hours of service in the 12 months before taking leave;* and
• Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite.
*Special “hours of service” requirements apply to airline ight crew employees.
Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice,
an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.
Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine
if the leave qualies for FMLA protection. Sufcient information could include informing an employer that the employee is or
will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or
continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which
FMLA leave was previously taken or certied.
Employers can require a certication or periodic recertication supporting the need for leave. If the employer determines that the
certication is incomplete, it must provide a written notice indicating what additional information is required.
Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the
employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and
responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.
Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as
FMLA leave.
Employees may le a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit
against an employer.
The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective
bargaining agreement that provides greater family or medical leave rights.
LEAVE
ENTITLEMENTS
BENEFITS &
PROTECTIONS
ELIGIBILITY
REQUIREMENTS
1-866-4-USWAGE
www.dol.gov/whd
For additional information or to file a complaint:
(1-866-487-9243) TTY: 1-877-889-5627
U.S. Department of Labor Wage and Hour Division
THE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISION
WH1420 REV 04/16
REQUESTING
LEAVE
EMPLOYER
RESPONSIBILITIES
ENFORCEMENT
Page 1 CONTINUED ON NEXT PAGE WH-384 R evised February 2013
Certification of Qualifying Exigency U.S. Department of Labor
For Military Family Leave Wage and Hour Division
(Family and Medical Leave Act)
OMB Control Number: 1235-0003
Expires: 8/31/2021
SECTION I: For Completion by 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 qualifying exigency to submit a certification. Please complete Section I
before giving this form to your employee. Your response is voluntary, and 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 825.309.
Employer na
me: ____________________________________________________________________________________
Contact Information: _________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II fully and completely. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due
to a qualifying exigency. Several questions in this section seek a response as to the frequency or duration of the qualifying
exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine
FMLA coverage. Your response is required to obtain a benefit. 29 CFR 825.310. While you are not required to provide
this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at
least 15 calendar days to return this form to your employer.
Your Name:
_______________________________________________________________________________________
First Middle Last
Name of military member on covered active duty or call to covered active duty status:
__________________________________________________________________________________________________
First Middle Last
Relation
ship of military member to you: ___________________________________________________________
Period of m
ilitary member’s covered active duty: __________________________________________________________
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written
documentation confirming a military member’s covered active duty or call to covered active duty status. Please check one
of the following and attach the indicated document to support that the military member is on covered active duty or call to
covered active duty status.
A copy of the military member’s covered active duty orders is attached.
Other documentation from the military certifying that the military member is on covered active duty (or has been
notified of an impending call to covered active duty) is attached.
I have previously provided my employer with sufficient written documentation confirming the military member’s
covered active duty or call to covered active duty status.
The TJX Companies, Inc. or its subsidiaries
HR XPRESS 1-888-627-6299, LOA Option
Page 2 CONTINUED ON NEXT PAGE WH-384 R evised February 2013
PART A: QUALIFYING REASON FOR LEAVE
1. Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you
are requesting leave):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2. A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes
any available written documentation which supports the need for leave; such documentation may include a copy of
a meeting announcement for informational briefings sponsored by the military; a document confirming the military
member’s Rest and Recuperation leave; a document confirming an appointment with a third party, such as a
counselor or school official, or staff at a care facility; or a copy of a bill for services for the handling of legal or
financial affairs. Available written documentation supporting this request for leave is attached.
Yes
No None Available
PART B: AMOUNT OF LEAVE NEEDED
1. Approximate date exigency commenced: __________________________________________________________
Probable duration of exigency: __________________________________________________________________
2. Will you need to be absent from work for a single continuous period of time due to the qualifying exigency?
Yes
No
If so, estimate the beginning and ending dates for the period of absence:
___________________________________________________________________________________________
3. Will you need to be absent from work periodically to address this qualifying exigency? Yes
No
Estimate schedule of leave, including the dates of any scheduled meetings or appointments:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time
(
i.e.
, 1 deployment-related meeting every month lasting 4 hours):
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours ___ day(s) per event.
Page 3 WH-384 Revised February 2013
PART C:
If leave is requested to meet with a third party (such as to arrange for childcare or parental care, to attend counseling, to
attend meetings with school, childcare or parental care providers, to make financial or legal arrangements, to act as the
military member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing
military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and
sufficient certification includes the name, address, and appropriate contact information of the individual or entity with
whom you are meeting (
i.e.
, either the telephone or fax number or email address of the individual or entity). This
information may be used by your employer to verify that the information contained on this form is accurate.
Name of Individual: ______________________________ Title: ______________________________________________
Organization: ______________________________________________________________________________________
Address: __________________________________________________________________________________________
Telephone: (________) ___________________________ Fax: (_______) ______________________________________
Email: ____________________________________________________________________________________________
Describe nature of meeting: ___________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PART D:
I certify that the information I provided above is true and correct.
Signature of Employee ___________________________________________ 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. 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. T he 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 EMPLOYER.
click to sign
signature
click to edit
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
Expires: 8/31/2021
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
CFR 825.125
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.
A comp
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
SECTION I: For Completion by the EMPLOYEE and/or the CURRENT 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 the current
servicemember):
____________________________________________________________________________________________
Name of Employee Requesting Leave to Care for the Current Servicemember:
____________________________________________________________________________________________
First Middle Last
Name of the Current Servicemember (for whom employee is requesting leave to care):
____________________________________________________________________________________________
First Middle Last
Relationship of Employee to the Current Servicemember:
Spouse
Parent Son Daughter Next of Kin
Part B: SERVICEMEMBER INFORMATION
(1) Is the Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves?
Yes
No
If yes, please provide the servicemember’s military branch, rank and unit currently assigned to:
_______________________________________________________________________________________
Is the 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 Servicemember on the Temporary Disability Retired List (TDRL)?
Yes
No
Part C: CARE TO BE PROVIDED TO THE SERVICEMEMBER
Describe the Care to Be Provided to the Current Servicemember and an Estimate of the Leave Needed to Provide the
Care:
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 2 Form WH-385 Revised May 2015
The TJX Companies, Inc. or its subsidiaries - HR XPRESS 1-888-627-6299, LOA Option
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 CFR
825.125. 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; (4) a DOD non-network TRICARE authorized private health care
provider, or (5) a health care provider as defined in 29 CFR 825.125:
_____________________________________________________________________
Telephone: ( ) _____________ Fax: ( ) ______________ Email: ___________________________________
PART B: MEDICAL STATUS
(1) The current 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-F or an employer-provided form seeking the
same information.)
(2) Is the current Servicemember 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: ______________________________________
Page 3 Form WH-385 Revised May 2015
(5) Is the servicemember undergoing medical treatment, recuperation, or therapy for this condition? Yes
No
If yes, please describe medical treatment, recuperation or therapy:
_________________________________________________________________________________________
PART C: SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1) Will the 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 servicemember require periodic follow-up treatment appointments? Yes
No
If yes, estimate the treatment schedule: __________________________________________
(3) Is there a medical necessity for the servicemember to have periodic care for these follow-up treatment
appointments? Yes
No
(4) Is there a medical necessity for the 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
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 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 Revised May 2015
click to sign
signature
click to edit
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: 8/31/2021
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
INSTRUCTI
ONS 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
Relat
ionship 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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