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Certification of Health Care Provider for
U.S. Department of Labor
Family Member’s Serious Health Condition
(Family and Medical Leave Act)
Wage and Hour Division
OMB Control Number: 1235-0003
Expires: 8/31/2021
SECTION I: For Completion by the EMPLOYER
INSTRUCTIO
NS 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 to care for a covered family
member with a serious health condition to submit a medical certification issued by the health care provider of the
covered family member. 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’ 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,
and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Employer name and contact: _______
______________________________________________________________
SECTION II: For Completion by the
EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family
member or his/her me
dical 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 to care for a covered family
member with a 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 to your employer. 29 C.F.R. § 825.305.
Your name: ___________________________________________________________
_______________________
First Middle Last
Name of family member for whom you will provide care:______________________________________________
First Middle Last
Relationship of family member to you: _____________________________
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If family member is your son or daughter, date of bir
t
h:____
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Describe care
y
ou will
provide to your family member and estimate leave needed to provide care:
Employee Signature Date
Page 1 CONTINUED ON NEXT PAGE
Form WH-380-F Revised May 2015
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
Town of Concord - Human Resources - Stephanie Oliver
22 Monument Square, PO Box 535, Concord, MA 01742 Phone: 978-318-3025 Fax: 978-318-3024