Certification of Health Care Provider for                                          U.S. Department of Labor 
Family Member’s Serious Health Condition                                           Wage and Hour Division 

under the Family and Medical Leave Act 

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR.                                                    OMB Control Number: 1235-0003 
RETURN TO THE PATIENT.                                                                                                               Expires: 6/30/2026 

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:
                                   First                     Middle                                       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                      Parent                      Child, under age 18 
             Child, age 18 or older and incapable of self-care because of a mental or physical disability 

    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         Transportation 
              Physical Care            Psychological Comfort                   Other: 

 (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: 
 
 PART A: Medical Information 
 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). 
 
 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