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

Certification of Health Care Provider for 
 
Employee’s Serious Health Condition 
 

 

U.S. Department of Labor 
 
Wage and Hour Division 
 

 

 

nder the Family and Medical Leave Act 
 

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

 u

 

 

 

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: _______________________________________________________________________________
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.) 
 

 

 

 

 

 

 

 

 

 

 

(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 
 

 

 

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 
________________ (mm/dd/yyyy) for the period of incapacity. 

 
 

 

 

the  beginning  date  ___________________ 

(mm/dd/yyyy)  and  end  date 

 

(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:
 
 
 
_____________________________________________________________________________________________
 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________________________________________________________

 
  
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. 

 

 

           

Form WH-380-E, Revised June 2020 
 

 

 

 

   

 

 

 

 

   

 

 

 
Page 4 of 4