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Certification of Health Care Provider for
U.S. Department of Labor
Employee’s Serious Health Condition
(Family and Medical Leave Act)
Wage and Hour Division
OMB Control Number: 1235-0003
Expires: 2/28/2015
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 protections because of a need for leave due to a serious health condition to
submit a medical certification issued by the employee’s health care provider. Please complete Section I before giving
this form to your employee. 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. §§ 825.306-825.308.
Employers must generally maintain records and documents relating to medical certifications, recertifications, or
medical histories of employees 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.
Employer name and contact: __________________________________________________________________
Employee’s job title: _____________________________ Regular work schedule: _______________________
Employee’s essential job functions: _____________________________________________________________
Check if job description is attached: _____
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical
provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical
certification to support a request for FMLA leave due to your own serious health condition. If requested by your
employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613,
2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA
request. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R.
§ 825.305(b).
Your name: __________________________________________________________________________________
First Middle Last
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROV
IDER: Your patient has requested leave under the FMLA.
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.
Please be sure to sign the form on the last page.
Provider’s name and business address: ___________________________________________________________
Type of practice / Medical specialty: ____________________________________________________________
Telephone: (________)________________________
____ Fax:(_________)_____________________________
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PART A: MEDICAL FACTS
1. Approximate date condition commenced: _______________
_______________________________________
Probable duration of condition: ______________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospi
ce, or residential
m
e
dical care facility
?
___No ___Yes. If so, dates of admission:
Date(s) you tr
eated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition? ___No
___ Yes.
Was medication, other than over-the-counter medication, prescribed? ___No
___Yes.
Was the patient referred to other health care provider(s) for evaluation or treatm
e
nt (e.g.,
phy
s
ical therapist)?
____No ____Yes. If so, state the nature of such treatments and expected duration of treatment:
2.
Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ________
____________
3. Use the information provided by the employer in Section I to a
n
swer this question. If the
em
ploy
er fails to
provide a list of the employee’s essential functions or a job description, answer these questions based upon
the employee’s own description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition
: ____ No ____ Yes.
If so, identify the job functions the employee is unable to perform:
4. Describe other relevant medical facts, if any, related to the condition for which the employ
ee seeks leave
(such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use
of specialized equipment):
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PART B: AMOUNT OF LEAVE NEEDED
5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,
including any time for treatment and recovery
? ___No ___Yes.
If so, estimate the beginning and ending dates for the period of incapacity: _______________________
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced
schedule because of the employ
ee’s medical condition? ___No ___Yes.
If so, are the treatments or the reduced number of hours of work medically necessary?
___
No ___Yes.
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time
required for each appointment, includi
ng any recovery period:
Estimate the part-time or reduced work schedule the e
m
ploy
ee needs, if any
:
____
______ hour(s) per day; ______
____ days per week from _____________ through _____________
7. Will the condition cause episodic flare-ups periodically preventing the employee from perform
ing his/her job
functions? ____No ____Yes.
Is it medically necessary for the employee to be absent from work during the flare-ups?
____
No
____
Yes
. If so,
explain:
Based upon the patient’s medical history and your knowledge of t
he medical condition, estimate the
frequency of
flare-ups and the duration of related incapacity that the patient may have over the next 6
months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency : _____ times per _____ week(s) _____ month(s)
Duration: _____ hours or ___ day(s) per episode
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL
ANSWER.
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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 y
ears. 29 U.S.C. § 2616; 29
C.F.R. § 825.500. Persons are not required to respond to this collection of information unle
ss 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 COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
Page 4 Form WH-380-E Revised January 2009
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