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U.S. Department of Labor (East Central College)

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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: 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 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.
Employer name and contact: ________________________________________
_____________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please com
plete Section II before giving this form to your family
member or his/her 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 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 mem
ber to you: _____________________________________________________________
If family member is your son or daughter, date of bir
t
h:____
___
___
_
____
___
___
________________________
Describe care you 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 January 2009
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under
the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. 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 patient needs leave. Page 3 provides space for additional
information, should you need it. Please be sure to sign the form on the last page.
Provider’s name and business address:______________________________________________________________
Type of practice / Medical specialty: ______________________________________________________________
Telephone: (________)_______
_____________________ Fax:(_________)_______________________________
PART A: MEDICAL FACTS
1. Approximate date condition commenced: ______
_________
__________________________________________
Probable duration of condition: _________________________________________________________________
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 treated the patient for condition: _________
_____________________________________________
Was
medication, other than over-the-counter medication, prescribed?
___
No
___Yes.
Will the patient need to have treatment visits at least twice per year due to the conditi
on? ___No ____ Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., phy
sical 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. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (s
uch
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of
specialized equipment):
Page 2 CONTINUED ON NEXT PAGE Form WH-380-F Revised January 2009
__________________________________________________________________________________________
PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need
for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or
transportation needs, or the provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treat
ment and
recovery? ___No ___Yes.
Estimate the beginning and ending dates for the perio
d
of incapacity
:
___________________________________
During this time, will the patient need care? __ No __ Yes.
Explain the care needed by the patient and why such care is medically necessary:
5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes.
Estimate treatment schedule, if any, including the dates of any
scheduled appointments and the time required for
each appointment, including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary
: ________________________
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? __
No __
Yes.
Estim
a
te the
hours the pati
ent needs care on an intermittent basis, if any:
________ hour(s) per day; ________ days per week from _________________ through __________________
Explain the care needed by the patient, and why such care is medically necessary:
Page 3 CONTINUED ON NEXT PAGE Form WH-380-F Revised January 2009
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________ ____________________________________________
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily
activities? ____No ____Yes.
Based upon th
e patient’s medical history and your knowledge of t
h
e medical co
ndition, 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
Does the patient need care during these flare-ups? ____ No ____ Yes.
Explain the care needed by the patient, and why
such care is medically necessary
: ________________________
____ ___
____ ___
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
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. 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 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-F Revised January 2009
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Completed 26 July 2020

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