CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
(FAMILY AND MEDICAL LEAVE ACT)
5/2008 Texas Association of School Boards. All rights reserved.
OMB Control Number: 1215-0181
Form WH-380-E November 2008
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 medication certifications, re-certifications, 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
Employer Name and Contact:
Birdville Independent School District
Melissa Sims / Human Resources
( 817) 547-5764 office / (817) 547-5536 fax
Employee’s Job Title: Regular Work Schedule: ________________
Employee’s Essential Job Functions: ________________________________________________________________
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,
29 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form, 29 C.F.R.
Your Name:_______________________________ ______________________ _____________________________
First Middle Last
Section III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA.
Answer, fully and completely, all applicable parts. Several questions seek a response as to 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: _______________________________________________________________
( ) Fax: ( )