Fillable Form 1: FAMILY & MEDICAL LEAVE ACT (FMLA)

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Form 1: FAMILY & MEDICAL LEAVE ACT (FMLA)

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1
FAMILY & MEDICAL LEAVE ACT (FMLA)
This packet must be given to an employee who will be or who has been absent more than 3
days for a personal or family illness, or for childbirth, adoption or foster placement of a child.
Thirty (30) days’ notice is required for foreseeable medical leave.
➢ The Request for Family & Medical Leave of Absence form (page 11) must be
completed and returned to Human Resources.
➢ There are two medical certification forms: (1) Certification of Health Care Provider for
Employee’s Own Serious Health Condition, and (2) Certification of Health Care Provider
for Family Member’s Serious Health Condition. Only the certification form applicable
to the employee’s need for medical leave of absence must be completed and
returned to Human Resources.
➢ Medical certification forms for military leave entitlements are available upon request from
Human Resources.
➢ Supervisors may not contact an employee’s health care provider for clarification and/or
verification of information related to an employee’s medical leave.
➢ Employees out of work under FMLA are NOT to perform any Henrico County Public
School (HCPS) job functions, to include checking HCPS e-mail, lesson planning, etc.
➢ A fitness for duty report/return to work note from the employee’s doctor is required and
must be submitted to Human Resources PRIOR to an employee returning from leave
involving the employee’s own serious health condition. The report/note must state the
employee’s ability to perform essential job functions and the effective return to
work date. Any restrictions must be reviewed and approved by Human
Resources prior to an employee returning to work. Medical notes and reports are
NOT to be retained at the school or department level.
2
FMLA CHECKLIST
❏ Read pages 1- 7 of FMLA packet. These pages contain a lot of useful information
regarding FMLA and may answer most of your questions regarding a medical leave of
absence.
❏ Keep pages 1 - 8 of this packet for your reference.
❏ Complete page 9 and return to the Payroll Department.
❏ Complete the Request for Family & Medical Leave of Absence form (page 11) in its
entirety.
● Provide beginning date of leave and expected return to work date, even if the
dates are tentative.
● Sign and date the form.
● Return completed form to HR as soon as possible.
❏ Complete the “employee portion” of the applicable medical certification form and have
the rest of the form completed in its entirety by your medical provider.
❏ Ask your school/department secretary to notify Human Resources
(hcpsfmla@henrico.k12.va.us) and Payroll (hcpspayroll@henrico.k12.va.us) via email
the first day you go out of work.
❏ In cases of birth of a child, notify Human Resources (hcpsfmla@henrico.k12.va.us) and
Payroll (hcpspayroll@henrico.k12.va.us) of the delivery date of your baby, as well as the
delivery type. You must notify Benefits (hcpsbenefits@henrico.k12.va.us) within 60 days
following the birth of a child if you wish to add your child to your insurance.
❏ Contact Payroll (hcpspayroll@henrico.k12.va.us or 804.652.3623) for Short-Term
Disability information, if applicable.
❏ Contact Benefits (804.652.3624 or hcpsbenefits@henrico.k12.va.us) to make
arrangements for payment continuation of health insurance and other voluntary
deductions should you run out of paid leave (sick, annual and/or personal) to cover your
leave of absence.
❏ Return both the Request for Family & Medical Leave of Absence form (page 11) and the
applicable medical certification form directly to Human Resources at Central Office.
NOTE: It is your responsibility to follow up with your physician regarding the
completion of the medical certification form.
❏ Submit a fitness for duty report/return to work note from your doctor to Human
Resources PRIOR to returning from leave if returning from leave involving your own
serious health condition. The report/note must state your ability to perform your
essential job functions and the effective return to work date. Any restrictions
must be reviewed and approved by Human Resources prior to an employee
returning to work.
NOTE: IT IS YOUR RESPONSIBILITY TO ALWAYS KEEP YOUR PRINCIPAL OR
SUPERVISOR INFORMED OF YOUR PROGRESS AND OF YOUR EXPECTED RETURN TO
WORK.
3
FAMILY AND MEDICAL LEAVE ACT (FMLA)
The Family and Medical Leave Act (FMLA) of 1993 entitles eligible employees up to 12 weeks
of unpaid leave within a 12-month period for the birth, placement for adoption, or foster care of a
child; to care for a spouse, parent, or child with a serious health condition. In addition, family
medical leave may be used to care for a spouse, son, daughter, parent, or next of kin injured in
the line of duty (26 weeks), or to take care of any qualifying exigency resulting from a call to
active duty (12 weeks). In addition, Henrico County Public Schools (HCPS) provides up to one
(1) additional week of job protection to employees out of work due to FMLA (i.e. 5 work days) of
leave beyond the 12-week FMLA entitlement, for a total of 13 weeks (65 days) in the applicable
12-month period. The 12-month period is determined by the first leave date of absence (ex.
The first date of absence is October 1, 2013. The 12-month period is October 1, 2013 through
September 30, 2014.)
Employees approved for FMLA are entitled to be returned to their same or an equivalent
position upon their return from medical leave of absence.
Note: If both spouses work for the school system, the total leave for both spouses in any 12-
month period is limited to 13 weeks (65 days) if leave is taken (a) for the birth or adoption of a
child, or (b) to care for a sick parent (personnel policy P4-08-016).
ELIGIBILITY
To be eligible for FMLA, an employee must have worked for HCPS for at least 1250 hours over
the 12 months preceding the start of the leave and have at least 12 total months of service with
Henrico County.
AMOUNT OF LEAVE
● Up to 12 weeks of unpaid, job-protected FMLA leave
● Up to 1 additional unpaid week (i.e. 5 work days) of job protection beyond FMLA,
provided by HCPS
Note: HCPS uses a “rolling” 12-month period measured backward from the date
an employee uses any FMLA leave. Under the “rolling” 12-month period, each
time an employee takes FMLA leave, the remaining leave entitlement would be the
balance of the 12 weeks which has not been used during the immediately
preceding 12 months.
Leave may be taken continuously or intermittently (except following the birth of a child), as
determined by the employee’s medical doctor.
In addition, worker’s compensation leave runs concurrently with FMLA leave.
4
REASONS FOR FMLA LEAVE
● Pregnancy, including the birth of a child and to care for the newborn child within one
year of birth;
● Placement of a child for adoption or foster care (leave must be taken within one year of
placement);
● To care for a parent, spouse, son, or daughter with a serious health condition;
● A serious health condition that renders an employee unable to perform the essential
functions of his or her job;
● Any qualifying exigency arising out of the fact that the employee’s spouse, son,
daughter, or parent is a military member on covered active duty or called to covered
active duty status;
● 26 workweeks of leave during a single 12-month period to care for a covered service
member with a serious injury or illness, when the employee is the spouse, son,
daughter, parent or next of kin of the service member.
PAID LEAVE
HCPS requires all applicable paid leave (sick, annual and personal leave) be exhausted before
unpaid leave is granted during the 13-week job protection period, unless the employee has
short-term disability insurance and elects to receive this during his/her medical leave. In this
case, the employee must use any available sick, annual, and/or personal leave during the
prescribed waiting period of his/her policy prior to the commencement of insurance payments.
Please note that sick leave taken for pregnancy, birth of a child, personal illness, or care of a
sick family member can only be taken for the time the employee or the family member is under
the care of a physician, up to 13 weeks (65 work days).
❖ LEAVE FOR THE BIRTH OF A CHILD
Employees taking medical leave for the birth of a child are allowed to utilize available
sick leave for the duration of recovery time indicated by the employee’s doctor on the
medical certification form for the employee’s own medical condition (typically 6 weeks for
vaginal delivery and 8 weeks for a Cesarean Section). If applicable, short-term disability
insurance may be substituted after the appropriate waiting period. Once the period
under the care of the doctor is completed, then additional leave taken would be annual,
personal, and/or leave without pay, up to a total of 13 weeks (if eligible). NOTE: A
teacher who does not work during the summer may take up to 13 weeks of job protected
leave (if eligible) beginning the first day of the contractual year; however, available sick
leave or short-term disability will end once the period under the care of the doctor is
completed.
5
REQUESTING LEAVE
Employees are required to request FMLA at least 30 days before leave is to begin when the
need for leave is foreseeable. In other cases, employees should request leave as soon as
practicable.
Employees requesting intermittent leave or leave on a reduced work schedule for planned
medical treatment must submit a completed medical certification form stating the dates on which
medical treatment is expected to be given and the duration of such treatment.
Employees must submit both the Request for Family & Medical Leave of Absence Form and
the appropriate medical certification form. Failure to provide sufficient information may result in
the delay or denial of the FMLA request. Requests for medical leave will be reviewed, and
notification of approval/denial will be sent to the employee, the employee’s Principal or
supervisor, HCPS Benefits Department, and HCPS Payroll Department. When practical, the
notification will be sent via email to the employee.
Please note that some health care providers charge a fee to complete medical certification
forms. HCPS does not reimburse any employee for the cost of obtaining medical certification.
In addition, HCPS reserves the right to require a second opinion at the school division’s
expense. A third opinion, at the school division’s expense, may be required if the first and
second opinion disagree.
SCHEDULING LEAVE
If leave is taken on an intermittent or reduced schedule basis for planned medical appointments
and treatments, it must be scheduled so it does not unduly disrupt the school division’s
operations. Special provisions exist for instructional personnel. If the requested intermittent
leave is for a classroom teacher or special education instructional assistant and constitutes 20%
or more time out, administration reserves the right to deny the request for intermittent leave and
required the employee to take the leave continuously. In addition, an instructional employee
requesting leave near the end of an academic term may be required to continue the leave until
the end of the term. NOTE: Intermittent leave is not available following the birth of a child.
6
HENRICO COUNTY PUBLIC SCHOOLS - FAMILY & MEDICAL LEAVE OF ABSENCE APPLICABLE
LEAVE TYPES
Before an employee is placed in a leave without pay status, he/she is required to use appropriate
accumulated leave (sick, personal, and/or annual leave) as outlined in personnel policy P4-08. .
● Sick Leave - All full time employees
earn unlimited accumulation of sick
leave. Sick leave may be used for an
employee’s own illness, or up to 65 days
for immediate family (spouse, parent, or
child). P4-08-001
● Annual Leave - All 260 days employees
earn annual leave. P4-08-008
● Extended Sick Leave - This may be
requested by eligible employees after all
accumulated leave is exhausted. An
employee must have completed three
(3) years of service with HCPS, have a
physician’s statement certifying the
necessity of continued absence, and
must be out 20 consecutive work days.
If approved, an employee will receive
the difference of his/her daily rate and
the rate of the board substitute (or the
first step of the employee’s pay grade).
P4-08-014
● Personal Leave - Granted to all full-
time employees. Personnel working less
than 12 months may accumulate a
maximum of 5 days. P4-08-009
● Catastrophic Leave - Refers to any
potentially terminal medical condition
that requires lengthy hospital or home
care for the employee only. Employees
out for 30 consecutive workdays may be
eligible for up to 45 days of paid
catastrophic leave (Employees are
eligible for 30 days of paid catastrophic
leave after one year of employment with
HCPS and for 45 days of paid
catastrophic leave after five years of
employment with HCPS.). Leave is
granted in 15 day increments with
physician’s update. Employees must
apply in writing for catastrophic leave.
P4-08-017
● Discretionary Leave - A leave of absence for
up to one year will be granted to an employee
with at least three (3) successful years of
experience with HCPS. Discretionary leave
may be taken for illness, family demands, or
other personal reasons. Application for
discretionary leave of absence must be made
in writing at the earliest possible date, but no
less that thirty (30) days prior to expected
commencement of leave. If the leave is being
requested for illness or disability, the leave of
absence will commence only after the leave
covered under FMLA has been taken.
Employees with documented performance
difficulties are not eligible for discretionary
leave. In addition, an employee must inform
the Director of Human Resources whether or
not he/she will return to active status no later
than February 1 of the school year preceding
the school year in which he or she is
scheduled to return from leave. Failure to
notify the Director of Human Resources will
result in termination of employment effective
the end of the leave period. P4-08-018, R4-08-
018
7
Payroll and Health Benefits
3820 Nine Mile Road
Henrico, Virginia 23223-0420
(804) 652-3623
hcpspayroll@henrico.k12.va.us
TO: HCPS Employee Out for Extended Absence
FROM: HCPS Payroll Office
The following is a set of guidelines to help you understand how your pay may be affected during your
absence.
➢ Please remember that FMLA is unpaid leave unless the employee has the appropriate leave
available, per HCPS Policy.
➢ If you apply for and are approved to take the 13 weeks of leave, time absent beyond the physician’s
documented return date must be covered by annual leave, personal leave, flexible sick leave, if
available, and/or leave without pay. (Refer to School Board Policy 4-08-016).
➢ Leave and/or leave without pay will only be charged for work days.
➢ Any benefit changes due to a qualifying life event (i.e. birth of a baby) must be made within 60
calendar days of the event.
➢ There may be pay periods during which the number of work hours exceeds the number of pay
hours. This may result in a leave without pay value that exceeds your monthly gross pay. The
difference will be deducted from your next paycheck.
➢ MetLife STIP and VRS Hybrid STD are not applicable to care for someone else.
MetLife Short-Term Income Protection
- VRS Plan 1 or Plan 2 Participants - hired prior to January 1, 2014 or previously enrolled in
VRS through a VRS participating employer, and VRS Hybrid employees enrolled to cover
first year of employment
- Employee responsible for filing claim
- Enrollment done as new hire or at open enrollment
- Pays 60% of salary
- Waiting period of 14, 28 or 42 days
- Can use paid leave beyond waiting period (must complete Payroll income protection form)
- Payment made directly to employees from MetLife
VRS Hybrid Short-Term Disability
- Employees hired on or after January 1, 2014 and were not already enrolled in VRS Plan 1
or Plan 2
- Employee responsible for filing claim
- Eligible after one (1) year of employment, automatic enrollment
- Waiting period of 7 days
- Payments processed through HCPS payroll, with normal payroll schedule
- Pays 60% of VRS Creditable Compensation, HCPS uses employees available paid leave
to supplement the additional 40% - until the disability period ends or leave is exhausted
8
PAGE INTENTIONALLY LEFT BLANK
9
Payroll and Health Benefits
3820 Nine Mile Road
Henrico, Virginia 23223-0420
(804) 652-3623
hcpspayroll@henrico.k12.va.us
To be returned to the Payroll Office
To better assist you with information you may need, please check one of the following:
□ My FMLA absence is to care for someone
□ My FMLA absence is for myself
□ My FMLA absence is a worker’s compensation incident
□ My FMLA absence is for the birth of a child
I will need to add my child as a dependent to my HCPS health plan
To provide you with accurate information, please check any that apply:
□ I am a VRS Plan 1 or Plan 2 employee and I plan to file a claim with MetLife
□ I am a VRS Plan 1 or Plan 2 employee and I do not plan to file a claim with MetLife
□ I am a VRS Hybrid employee and I will file a claim with The Standard
□ I do not know which VRS plan I am in
□ I do not know if I am enrolled in MetLife STIP
□ I would like additional information sent to me
*Please include an email address and phone number below
Email: _______________________________________________________
Phone: _______________________________________________________
Name: _______________________________________________________
Beginning Date of Leave:
10
PAGE INTENTIONALLY LEFT BLANK
11
REQUEST FOR FAMILY & MEDICAL LEAVE OF ABSENCE
RETURN TO: HCPS HUMAN RESOURCES VIA EMAIL AT HCPSFMLA@HENRICO.K12.VA.US, FAX:
804.652.3763, OR MAIL TO HCPS HUMAN RESOURCES, 3820 NINE MILE ROAD, HENRICO, VA 23223.
*To be eligible for FMLA, you must have at least 12 months of service with Henrico County Public Schools (HCPS)
and/or Henrico County and have worked 1250 hours over the 12 months prior to the commencement of leave.
PLEASE NOTE: If eligible, up to 12 weeks (60 workdays) of FMLA may be taken within a 12-month period for
qualifying reasons. In addition, HCPS provides up to one (1) additional week of job protection to employees out of
work due to FMLA (i.e. 5 work days), for a total of 13 weeks (65 days) in an applicable 12-month period. During
these 13 weeks, you may use available sick leave only for the time you or your family member are under the care of a
physician.
NAME:
PREFERRED EMAIL ADDRESS:
POSITION:
WORK LOCATION:
BEGINNING DATE OF LEAVE:
EXPECTED DATE OF RETURN:
REASON FOR REQUEST (Please check one):
⬜ Birth of a child (Certification of Health Care Provider for Employee’s Own Illness or Certification of Family
Member’s Illness required.)
⬜ Placement for adoption or foster care of a child (Copies of court papers/placement documentation required.)
⬜ Unable to perform job functions due to own serious health condition, including pregnancy-related incapacity and
prenatal care (Certification of Health Care Provider for Employee’s Own Illness required.)
⬜ Care for a spouse, child under 18, child 18 years or older and incapable of self-care due to a mental or physical
disability, or parent with serious health condition (Certification of Family Member’s Illness required.)
⬜ Military caregiver leave of a covered service member with a serious injury or illness (Certification for Serious
Injury or Illness of Covered Service member required.)
⬜ A qualifying exigency arising out of the fact that your spouse, child, or parent is on covered active duty or has been
notified of an impending call to covered active duty status with the Armed Forces (Copy of active duty orders
required.)
Do you have a spouse who works for HCPS who is also requesting FMLA for the same reason during this
time?
⬜ YES - Name: ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⎽ ⬜ NO
I certify that the information given on this form is true. I understand that making false statements on this form is
grounds for discipline, up to and including termination of my employment.
SIGNATURE:
DATE:
____________________________________________________________________________________________________________________
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. 29 U.S.C. §§ 2613, 2614(c)(3); 29 C.F.R. § 825.305. The employer must give the employee at least
15 calendar days to provide the certification. If the employee fails to provide complete and sufficient medical 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, this form asks the health
care provider for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R.
§ 825.306. You may not ask the employee to provide more information than allowed under the FMLA regulations,
29 C.F.R. §§ 825.306-825.308. Additionally, you may not request a certification for FMLA leave to bond with a healthy
newborn child or a child placed for adoption or foster care.
Employers must generally maintain records and documents relating to medical information, 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, 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) The medical 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.)
(4) Employee’s job title: ___________________________________________ Job description ( is / is not) attached.
Employee’s regular work schedule: __________________________________________________________________
Statement of the employee’s essential job functions: ____________________________________________________
(The essential functions of the employee's position are determined with reference to the position the employee held at the time the employee
notified the employer of the need for leave or the leave started, whichever is earlier.)
SECTION II - HEALTH CARE PROVIDER
Please provide your contact information, complete all relevant parts of this Section, and sign the form. Your patient has
requested leave under the FMLA. The FMLA allows an employer to require that the employee submit a timely, complete,
and sufficient medical certification to support a request for FMLA leave due to the serious health condition of the employee.
For FMLA purposes, a “serious health condition” means an illness, injury, impairment, or physical or mental condition that
involves inpatient care or continuing treatment by a health care provider. For more information about the definitions of a
serious health condition under the FMLA, see the chart on page 4.
You may, but are not required to, provide other appropriate medical facts including symptoms, diagnosis, or any regimen
of continuing treatment such as the use of specialized equipment. Please note that some state or local laws may not allow
disclosure of private medical information about the patient’s serious health condition, such as providing the diagnosis and/or
course of treatment.
Page 1 of 4 Form WH-380-E, Revised June 2020
U.S. Department of Labor
Wage and Hour Division
Certification of Health Care Provider for
Employee’s Serious Health Condition
under the 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: 6/30/2023
_______________________________________________________________________________________
Employee Name: ____________________________________________________________________________________________
Health Care Provider’s name:
(Print) ____________________________________________________________________
Health Care Provider’s business address: ________________________________________________________________
Type of practice / Medical specialty: ___________________________________________________________________
Telephone: (___) ______________ Fax: (___) ______________ E-mail: _______________________________________
PART A: Medical Information
Limit your response to the medical condition(s) for which the employee is seeking FMLA leave. Your answers should be
your best estimate based upon your medical knowledge, experience, and examination of the patient. After completing
Part A, complete Part B to provide information about the amount of leave needed. Note: For FMLA purposes,
“incapacity” means the inability to work, attend school, or perform regular daily activities due to the condition, treatment
of the condition, or recovery from the condition. Do not provide information about genetic tests, as defined in 29 C.F.R. §
1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s
family members, 29 C.F.R. § 1635.3(b).
(1) State the approximate date the condition started or will start: ___________________________________
(mm/dd/yyyy)
(2) Provide your best estimate of how long the condition lasted or will last: ____________________________________
(3) Check the box(es) for the questions below, as applicable. For all box(es) checked, the amount of leave needed must be
provided in Part B.
Inpatient Care: The patient ( has been / is expected to be) admitted for an overnight stay in a hospital,
hospice, or residential medical care facility on the following date(s):
______________________________
Incapacity plus Treatment: (e.g. outpatient surgery, strep throat)
Due to the condition, the patient ( has been / is expected to be) incapacitated for more than three
consecutive, full calendar days from ______________
(mm/dd/yyyy) to _____________ (mm/dd/yyyy).
The patient ( was / will be) seen on the following date(s): _____________________________________
The condition ( has / has not) also resulted in a course of continuing treatment under the supervision of a
health care provider
(e.g. prescription medication (other than over-the-counter) or therapy requiring special equipment)
Pregnancy: The condition is pregnancy. List the expected delivery date: _______________ (mm/dd/yyyy).
Chronic Conditions: (e.g. asthma, migraine headaches) Due to the condition, it is medically necessary for the patient
to have treatment visits at least twice per year.
Permanent or Long Term Conditions:
(e.g. Alzheimer’s, terminal stages of cancer) Due to the condition, incapacity
is permanent or long term and requires the continuing supervision of a health care provider (even if active
treatment is not being provided).
Conditions requiring Multiple Treatments:
(e.g. chemotherapy treatments, restorative surgery) Due to the condition,
it is medically necessary for the patient to receive multiple treatments.
None of the above: If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy)
no additional information is needed. Go to page 4 to sign and date the form.
Page 2 of 4
Form WH-380-E, Revised June 2020
_____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Employee Name: ____________________________________________________________________________________________
(4) If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks
FMLA leave.
(e.g., use of nebulizer, dialysis) _______________________________________________________
PART B: Amount of Leave Needed
For the medical condition(s) checked in Part A, complete all that apply. 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.
(5) Due to the condition, the patient ( had / will have) planned medical treatment(s) (scheduled medical visits)
(e.g. psychotherapy, prenatal appointments) on the following date(s): ___________________________________________
(6) Due to the condition, the patient ( was / will be) referred to other health care provider(s) for evaluation or
treatment(s).
State the nature of such treatments: (e.g. cardiologist, physical therapy) ________________________________________
Provide your best estimate of the beginning date ________________
(mm/dd/yyyy) and end date ________________
(mm/dd/yyyy) for the treatment(s).
Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery
(e.g. 3 days/week)
(7) Due to the condition, it is medically necessary for the employee to work a reduced schedule.
Provide your best estimate of the reduced schedule the employee is able to work. From ____________________
(mm/dd/yyyy) to __________________ (mm/dd/yyyy) the employee is able to work: (e.g., 5 hours/day, up to 25 hours a week)
(8) Due to the condition, the patient ( was / will be) incapacitated for a continuous period of time, including any
time for treatment(s) and/or recovery.
Provide your best estimate of the beginning date ___________________
(mm/dd/yyyy) and end date
________________
(mm/dd/yyyy) for the period of incapacity.
(9) Due to the condition, it ( was / is / will be) medically necessary for the employee to be absent from work on
an intermittent basis (periodically), including for any episodes of incapacity i.e., episodic flare-ups. Provide your
best estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.
Over the next 6 months, episodes of incapacity are estimated to occur ___________________________ times per
( day / week / month) and are likely to last approximately ______________ ( hours / days) per episode
.
Page 3 of 4
Form WH-380-E, Revised June 2020
■
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Employee Name: ____________________________________________________________________________________________
PART C: Essential Job Functions
If provided, the information in Section I question #4 may be used to answer this question. If the employer fails to provide a
statement of the employee’s essential functions or a job description, answer these questions based upon the employee’s own
description of the essential job functions. An employee who must be absent from work to receive medical treatment(s), such
as scheduled medical visits, for a serious health condition is considered to be not able to perform the essential job functions
of the position during the absence for treatment(s).
(10) Due to the condition, the employee ( was not able / is not able / will not be able) to perform one or more
of the essential job function(s). Identify at least one essential job function the employee is not able to perform:
Si
gnature of
Health Care Provider _____________________________________________ Date _________________ (mm/dd/yyyy)
Definitions of a Serious Health Condition
(See 29 C.F.R. §§ 825.113-.115)
Inpatient Care
• An overnight stay in a hospital, hospice, or residential medical care facility.
• Inpatient care includes any period of incapacity or any subsequent treatment in connection with the overnight stay.
Continuing Treatment by a Health Care Provider (any one or more of the following)
Incapacity Plus Treatment: A period of incapacity of more than three consecutive, full calendar days, and any subsequent treatment
or period of incapacity relating to the same condition, that also involves either:
o Two or more in-person visits to a health care provider for treatment within 30 days of the first day of incapacity unles
s
ex
tenuating circumstances exist. The first visit must be within seven days of the first day of incapacity; or
,
o At least one in-person visit to a health care provider for treatment within seven days of the first day of incapacity, which
r
esults in a regimen of continuing treatment under the supervision of the health care provider. For example, the healt
h
p
rovider might prescribe a course of prescription medication or therapy requiring special equipment
.
Pregnancy: Any period of incapacity due to pregnancy or for prenatal care.
Chronic Conditions: Any period of incapacity due to or treatment for a chronic serious health condition, such as diabetes, asthma,
migraine headaches. A chronic serious health condition is one which requires visits to a health care provider (or nurse supervised by
the provider) at least twice a year and recurs over an extended period of time. A chronic condition may cause episodic rather than a
continuing period of incapacity.
Permanent or Long-term Conditions: A period of incapacity which is permanent or long-term due to a condition for which
treatment may not be effective, but which requires the continuing supervision of a health care provider, such as Alzheimer’s disease
or the terminal stages of cancer
.
Conditions Requiring Multiple Treatments: Restorative surgery after an accident or other injury; or, a condition that would likely
result in a period of incapacity of more than three consecutive, full calendar days if the patient did not receive the treatment.
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 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, N.W., Washington, D.C. 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
Page 4 of 4 Form WH-380-E, Revised June 2020
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Form 1: FAMILY & MEDICAL LEAVE ACT (FMLA)

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Completed 14 May 2021

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