Fillable Printable Form WH-380-E

What is a Form WH-380-E ?

WH-380-E is a form in acquiring certification of health care provider for employee's serious health condition. And wh-380e is for use when the employee's need for leave is due to the employee's own serious health condition. Fill fillable form wh-380-e online, download blank or editable online. Sign, fax and print with Handypdf.com.

Fillable Printable Form WH-380-E

What is a Form WH-380-E ?

Form WH-380-E

Page 1 Form WH-380-E Revised May 2015

Certification of Health Care Provider for U.S. Department of Labor

Employee’s Serious Health Condition Wage and Hour Division

(Family and Medical Leave Act)

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OMB Control Number: 1235-0003

Expires: 5/31/2018

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 due to a serious health condition to submit a

medical certification issued by the employee’s health care provider. 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 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.

Employer name and contact: __________________________________________________________________

Employee’s job title: _____________________________ Regular work schedule: _______________________

Employee’s essential job functions: _____________________________________________________________

__________________________________________________________________________________________

Check if job description is attached: _____

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to y our 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 due to your own 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. 29 C.F.R. § 8 25.305(b).

Your name: __________________________________________________________________________________

First Middle Last

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer,

fully and completely, all applicable parts. 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 employee is seeking

leave. 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). 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: ______________________________________________________________

Mark below as applicable:

Was the patient admitted for an overnight stay in a hospital, hospi

ce, or residential

dical care facility

___

___Yes.

If so, dates of ad

mission:

Date(s) you tr

eated the patient for condition:

Will the patient need to have treatment visits at least twice per y

ear due to the condition? ___No ___ Yes.

Was medication, other than over-the-counter medication, prescribed? ___

No ___Yes.

Was the patient referred to other health care provider(s) for evaluation or treatm

nt (e.g.,

phy

ical therapist)

____

_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. Use the information provided by the em

ployer in Section I to a

swer this question. If the

ploy

er fail

s to

provide a list

of the em

ployee’

s essential

functions or a

job descripti

on, answer these questions based upon

the employee’s own description of his/her job functions.

Is the employee unable to perform any of his/her job functions due to the condition: ____ No ____ Yes.

If so, identify the job functions the em

ployee is unable to perform:

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave

(such medical facts may inc

lude symptoms, diagnosis, or any regimen of continuing treatment such as the use

of specialized equipment):

Page 2 CONTINUED ON NEXT PAGE

Form WH-380-E Revised May 2015

____________________________________________________________________________________

__________________________________________________________________________________________

PART B: AMOUNT OF LEAVE NEEDED

5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,

including any time for treatment and recovery? ___No ___Yes.

If so, estimate the beginning and ending dates for the period of incapacity: _______________________

6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced

schedule because of the employee’s medical condition? ___No

___Yes.

If so, are the treatments or the reduced number of hours of work m

dically necessary?

___No ___Yes.

Estimate treatment schedule, if any, incl

uding the dates of any scheduled appointments and the time

required for each appointment, including any recovery period:

Estimate the part-time or reduced work schedule the e

ploy

ee needs, if any

____

___

___ hour(s) per d

___

__ days per week

from _____________ through _____________

7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job

functions? ____No ____Yes.

Is it medically necessary for the empl

oyee to be absent from work during the flare-ups?

____

Yes

. If so, explain:

Based upon the patient’s medical history

and your knowledge of t

he medical condition, estimate the

frequency of flare-ups and the duration of related incapacity that th

e 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

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUM

BER WITH YOUR ADDITIONAL

ANSWER.

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Form WH-380-E Revised May 2015

__________________________________________________________________________________________

__________________________________________ __________________________________________

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 n

ot required to respond to this collection of information unless it displays a currently valid OMB

control nu

mber. 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 COMPLET ED F ORM TO THE DEPART MENT OF LABOR; RET URN TO THE PATIENT.

Page 4

Form WH-380-E Revised May

2015