Certification of Health Care Provider for 
  
 
Family Member’s Serious Health Condition 
 
 
under the Family and Medical Leave Act 

 

 

 
U.S. Department of Labor 
Wage Hour Division 

 

             

  
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. 
RETURN TO THE PATIENT. 
 

 

 

 

 

 

OMB Control Number: 1235-0003 
 
Expires:  6/30/2023 
  
 

The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave to care for a 
family member with a serious health condition to submit a medical certification issued by the family member’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 or 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. 
  

 

 

 

 

 

 

 

 

 

(1)  Employee name: _____________________________________________________________________________________ 
Middle 
 

First 
 

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.) 

 

 

 

 

 

SECTION II - EMPLOYEE 
 
 

Please complete and sign Section II before providing this form to your family member or your family member’s health care provider. 
 
The FMLA allows an employer to require that you submit a timely, complete, and sufficient medical certification to support a request 
 
for FMLA leave due to the serious health condition of your family member.  If requested by your employer, your response is required 
 
 
to obtain or retain the benefit of the FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). You are responsible for making sure the 
 
medical certification is provided to your employer within the time frame requested, which must be at least 15 calendar days.  29 
C.F.R. §§ 825.305-825.306. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA 
leave request. 29 C.F.R. § 825.313. 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)  Name of the family member for whom you will provide care: _________________________________________________ 

 

 

(2)  Select the relationship of the family member to you. The family member is your: 

 

 

 

 

 Spouse 
 Child, age 18 or older and incapable of self-care because of a mental or physical disability 

 Parent 

 

 

 
 Child, under age 18 
 

 

Spouse  means  a  husband  or  wife  as  defined  or  recognized  in  the  state  where  the  individual  was  married,  including  in  a 
 
common law marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which 
a person assumes the obligations of a parent to a child. An employee may take FMLA leave to care for an individual who 
 
assumed the obligations of a parent to the employee when the employee was a child. An employee may also take FMLA 
 
leave to care for a child for whom the employee has assumed the obligations of a parent. No legal or biological relationship 
is necessary. 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 4 
 
 

Form WH-380-F, Revised June 2020 
 

 

 

 
Employee Name: ____________________________________________________________________________________________ 

 

(3)  Briefly describe the care you will provide to your family member: (Check all that apply) 
 Assistance with basic medical, hygienic, nutritional, or safety needs 
 Physical Care 

 Psychological Comfort 

 

 

 Other:   _______________________________________ 

 Transportation 

(4)  Give your best estimate of the amount of leave needed to provide the care described: ______________________________ 

 

 

___________________________________________________________________________________________________ 

 

(5)  If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced schedule 
you are able to work. From __________________ (mm/dd/yyyy) to ____________________ (mm/dd/yyyy), I am able to work 
__________________ (hours per day) __________________ (days per week). 

 

 

 

 

 

 

 

 

 

 

 

Employee 
 
Signature ___________________________________________________________ Date __________________ (mm/dd/yyyy) 
 
 

 

 

SECTION III - HEALTH CARE PROVIDER 
 

 

 

Please provide your contact information, complete all relevant parts of this Section, and sign the form below. A family member of your 
 
patient has requested leave under the FMLA to care for your patient. 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 to care for a family member with a serious 
 
health condition.  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 at the end of the form. 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You  also  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. 
 

 

 

 

 

 

 

 

 

     

Health Care Provider’s name: (Print) _________________________________________________________________________ 

 

 

Health Care Provider’s business address: _____________________________________________________________________ 

Type of practice / Medical specialty:  ________________________________________________________________________ 

Telephone: (_____) ________________ Fax: (____) ______________ E-mail: _______________________________________ 
 

 

 

 

 

   

Limit your response to the medical condition 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)  Patient’s Name: ______________________________________________________________________________________ 

(2)  State the approximate date the condition started or will start: _______________________________________ (mm/dd/yyyy) 

 

 

 

(3)  Provide your best estimate of how long the condition lasted or will last: _________________________________________ 

 

 

 

(4)  For FMLA to apply, care of the patient must be medically necessary.  Briefly describe the type of care needed by the patient 

 

 

 

(e.g., assistance with basic medical, hygienic, nutritional, safety, transportation needs, physical care, or psychological comfort). 
________________________________________________________________________________________________________ 
________________________________________________________________________________________________________ 

 

 

 
PART A:  Medical Information 

 

 
 
Page 2 of 4 

 
Form WH-380-F, Revised June 2020 

 

 

 
Employee Name: ____________________________________________________________________________________________ 

(5)  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. 

 

 

(6)  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 if the benefits and protections of the FMLA apply. 

 

 

 

 

 

 

 

 

 

 

(7)  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): ______________________________________________ 
 

 

_____________________________________________________________________________________________ 

(8)  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) 

 

 

 

 

 
 
Page 3 of 4 

 
Form WH-380-F, Revised June 2020 

 

 

Employee Name: ____________________________________________________________________________________________

 

 (9)  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. 

 

 

 

 

 

 
(10)  Due  to  the  condition  it,  ( was  /   is  /   will  be)  medically  necessary  for  the  employee  to  be  absent  from  work  to 
 
 
 
provide care for the patient 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. 

 

 

 

 

 

 

 
  
Signature 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  unless 
 
 
 

 
extenuating 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 
 
 
 
results  in  a  regimen  of  continuing  treatment  under  the  supervision  of  the  health  care  provider.  For  example,  the  health 
 
 
provider 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-F, Revised June 2020