Certification for Serious Injury or Illness of a   U.S. Department of Labor 
Veteran for Military Caregiver Leave 
under the Family and Medical Leave Act 

Wage and 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 eligible employees may take FMLA leave to care for a covered 
veteran with a serious illness or injury. The FMLA allows an employer to require an employee seeking FMLA leave for 
this purpose to submit a medical certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the employee at 
least 15 calendar days to provide the certification.  If the employee fails to provide complete and sufficient 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, it asks the health care 
provider for the information necessary for a complete and sufficient medical certification. Recertifications are not allowed 
for FMLA leave to care for a covered servicemember. Where medical certification is requested by an employer, an 
employee  may  not  be  held  liable  for  administrative  delays  in  the  issuance  of  military  documents,  despite  the 
employee's diligent, good-faith efforts to obtain such documents. In lieu of this form or your own certification form, you 
must  accept  as  sufficient  certification  of  the  veteran's  serious  injury  or  illness  documentation  indicating  the  veteran's 
enrollment in the Department of Veterans Affairs Program of Comprehensive Assistance for Family Caregivers.  You may 
not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310.  

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: ________________________________________________________________________________

First 

Middle 

Last 

(2) Employer Name: __________________________________________ Date: _______________________ (mm/dd/yyyy)

(List date certification requested) 

(3) This 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 and/or VETERAN 

Please complete all Parts in Section II before having the veteran’s health care provider complete Section III. The FMLA 
allows an employer to require that an employee submit a timely, complete, and sufficient certification to support a request 
for military caregiver leave under the FMLA due to a serious injury or illness of a covered veteran.  If requested by the 
employer, your response is required to obtain or retain the benefit of FMLA-protected leave. The employer must give an 
employee at least 15 calendar days to return this form to the employer. 29 U.S.C. §§ 2613, 2614(c)(3).  

PART A:  EMPLOYEE INFORMATION 

(1) Name of veteran for whom employee is requesting leave: ________________________________________________

First 

Middle 

Last 

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Form WH-385-V, Revised June 2020 

Employee Name: ____________________________________________________________________________________________ 

(2) Select your relationship to the veteran. You are the veteran’s:

 Spouse

 Parent

 Child

 Next of Kin

Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common law  
marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis in which a person assumes the obligations of a 
parent to a child. An employee may take FMLA leave to care for a covered servicemember 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 covered servicemember for whom 
the employee has assumed the obligations of a parent. No biological or legal relationship is necessary. “Next of kin” is the veteran’s 
nearest blood relative, other than the spouse, parent, son, or daughter, in the following order of priority: (1) a blood relative as designated 
in writing by the veteran for purposes of FMLA leave, (2) blood relatives granted legal custody of the veteran, (3) brothers and sisters, 
(4) grandparents, (5) aunts and uncles, and (6) first cousins.

PART B:  VETERAN INFORMATION AND CARE TO BE PROVIDED TO THE VETERAN 

(3) The veteran was ( honorably /  dishonorably) discharged or released from the Armed Forces, including the National

Guard or Reserves. List the date of the veteran’s discharge: _______________________________ (mm/dd/yyyy)

(4)  Please provide the veteran’s military branch, rank and unit at the time of discharge: ______________________________

_________________________________________________________________________________________________

(5) The veteran ( is /  is not) receiving medical treatment, recuperation, or therapy for an injury or illness.

(6) Briefly describe the care you will provide to the veteran: (Check all that apply)

 Assistance with basic medical, hygienic, nutritional, or safety needs

 Transportation

 Psychological Comfort

 Physical Care

 Other: __________________________

(7) Give your best estimate of the amount of FMLA leave needed to provide the care described: _______________________

_______________________________________________________________________________________________ 

(8) If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work

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).

SECTION III - HEALTH CARE PROVIDER 

Please provide your contact information, complete all Parts of this Section fully and completely, and sign the form below.  
The employee named in Section I has requested leave under the military caregiver leave provision of the FMLA to care for 
a family member who is a veteran.  

Note: For purposes of FMLA military caregiver leave, a serious injury or illness means an injury or illness incurred by the 
servicemember  in  the  line  of  duty  on  active  duty  in  the  Armed  Forces  (or  that  existed  before  the  beginning  of  the 
servicemember’s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces) and 
manifested itself before or after the servicemember became a veteran, and is: a continuation of  a serious injury or illness 
that  was  incurred  or  aggravated  when  the  covered  veteran  was  a  member  of  the  Armed  Forces  and  rendered  the 
servicemember unable to perform the duties of the servicemember’s office, grade, rank, or rating; or a physical or mental 
condition for which the covered veteran has received a U.S. Department of Veterans Affairs Service Related Disability 
Rating  (VASRD)  of  50  percent  or  greater,  and  such  VASRD  rating  is  based,  in  whole  or  in  part,  on  the  condition 
precipitating the need for military caregiver leave; or a physical or mental condition that substantially impairs the covered 
veteran’s ability to secure or follow a substantially gainful occupation by reason of a disability or disabilities related to 
military service, or would do so absent treatment; or an injury, including a psychological injury, on the basis of which the 
covered veteran has been enrolled in the Department of Veterans’ Affairs Program of Comprehensive Assistance for Family 
Caregivers.  

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Form WH-385-V, Revised June 2020 

Employee Name: ____________________________________________________________________________________________ 

“Need for care” includes both physical and psychological care. It includes situations where, for example, due to his or her 
serious injury or illness, the veteran is not able to care for his or her own basic medical, hygienic, or nutritional needs or 
safety, or needs transportation to the doctor.  It also includes providing psychological comfort and reassurance which would 
be beneficial to the veteran who is receiving inpatient or home care.  

A complete and sufficient certification to support a request for FMLA military caregiver leave due to a covered veteran’s 
serious injury or illness includes written documentation confirming that the veteran’s injury or illness was incurred in the 
line of duty on active duty or existed before the beginning of the veteran’s active duty and was aggravated by service in the 
line of duty on active duty, and that the veteran is undergoing treatment, recuperation, or therapy for such injury or illness 
by  a  health  care  provider  listed  above.    Information  about  the  FMLA  may  be  found  on  the  WHD  website 
at www.dol.gov/agencies/whd/fmla. 

PART A:  HEALTH CARE PROVIDER INFORMATION  

Health Care Provider’s Name: (Print) ___________________________________________________________________ 

Health Care Provider’s business address: _______________________________________________________________  

Type of Practice/Medical Specialty: ____________________________________________________________________ 

Telephone: (___) _______________ Fax: (___) _______________ E-mail: ____________________________________ 

Please select the type of FMLA health care provider you are:  

 DOD health care provider
 VA health care provider
 DOD TRICARE network authorized private health care provider
 DOD non-network TRICARE authorized private health care provider
 Health care provider as defined in 29 CFR 825.125

PART B:  MEDICAL INFORMATION 

Please provide appropriate medical information of the patient as requested below. Limit your responses to the veteran’s 
condition  for  which  the  employee  is  seeking  leave.    If  you  are  unable  to  make  certain  military-related  determinations 
contained below, you are permitted to rely upon determinations from an authorized DOD representative, such as a DOD 
Recovery Care Coordinator, or an authorized VA representative. Do not provide information about genetic tests, as defined 
in 29 C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e). 

(1) Patient’s Name: __________________________________________________________________________________

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

(3) Provide your best estimate of how long the condition will last:  ___________________________________________

(4) The veteran’s injury or illness: (Select as appropriate)

 Was incurred in the line of duty on active duty
 Existed before the beginning of the veteran’s active duty and was aggravated by

service in the line of duty on active duty

 None of the above

The veteran ( is /  is not) undergoing medical treatment, recuperation, or therapy for this condition. If yes, briefly 
describe the medical treatment, recuperation, or therapy: __________________________________________________ 

_______________________________________________________________________________________________ 

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Form WH-385-V, Revised June 2020 

Employee Name: ____________________________________________________________________________________________ 

(5) The veteran’s medical condition is:  (Select as appropriate)

 A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member
of the Armed Forces and rendered the servicemember not able to perform the duties of the servicemember’s office,
grade, rank, or rating.

 A physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs
Service Related Disability Rating (VASRD) of 50% or higher, and such VASRD rating is based, in whole or in part,
on the condition precipitating the need for military caregiver leave.

 A  physical  or  mental  condition  that  substantially  impairs  the  covered  veteran’s  ability  to  secure  or  follow  a
substantially gainful occupation by reason of a disability or disabilities related to military service, or would do so
absent treatment.

 An injury, including a psychological injury, on the basis of which the covered veteran is enrolled in the Department

of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.

 None of the above. Note to Employee:  If this box is checked, you may still be eligible to take leave to care for a covered
family member with a “serious health condition” under 29 C.F.R. § 825.113 of the FMLA. If such leave is requested, you
may be required to complete DOL FORM WH-380-F or an employer-provided form seeking the same information.

Part C:  Amount of Leave Needed 

For the medical condition checked in Part B, complete all that apply. Some 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 military caregiver leave coverage.  

(1) Due to the condition, the veteran will need care for a continuous period of time, including any time for treatment and
recovery.   Provide your best estimate of the beginning date _______________ (mm/dd/yyyy) and end date _____________
(mm/dd/yyyy) for this period of time.

(2) Due to the condition, it is medically necessary for the veteran to attend planned medical treatment appointments (scheduled 
medical  visits).      Provide  your  best  estimate  of  the  duration  of  the  treatment(s),  including  any  period(s)  of  recovery
_________________________________________________________________________ (e.g. 3 days/week)

(3) Due to the condition, it is medically necessary for the veteran to receive care on an intermittent basis (periodically), such
as the care needed because of episodic flare-ups of the condition or assisting with the veteran’s recovery. Provide your best
estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.

Over the next 6 months, intermittent care is 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) 

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, in accordance with  
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, NW, Washington, DC 20210.  

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

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Form WH-385-V, Revised June 2020