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Fillable Printable Form WH-385V

Fillable Printable Form WH-385V

Form WH-385V

Form WH-385V

Certification for Serious InjuryU.S. Department of Labor
or Illness of a Veteran forWage and Hour Division
Military Caregiver Leave
(Family and Medical Leave Act)
_____________________________________________________________________
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LAB OR; RETURN TO THE EMPLOYEEOMB Control Number: 1235-0003
Expires : 5/31/2018
Notice to the EMPLOYER
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military caregiver leave
under the FMLA leave d ue to a serious inj ury or illness of a covered veteran to submit a cer tification provid ing sufficient facts to
supp ort t he request for leave. Your response is voluntary. While you are not required to use this for m, you may not ask t heemployee
to provide more information than allowed under the FMLA regulations, 29 CFR 825.310. Employers must generally maintain records
and documents relating to medic a l c e rtifications, rece rtifications, or medical histories o f 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 CFR 1630.14(c )(1), if the Americans wi th Disabilities Act app lie s, and in accordance with 29 CFR 1635.9, if the Genetic
Information No ndiscrimination Act applie s.
SECTION I: For completion by the EMPLOYEE and/or the VETERAN for whom the employee is
requesting leave
INSTRUCTIONS to the EMPLOYEE and/or VETERAN:
Please complete Section I before having Section II completed.
The FMLA permits 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 leave 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. 29 U.S.C. 2613, 2614(c)(3). Failure to
do so may result in a denial of an employee’s FMLA request. 29 CFR 825.310(f). The employer must give an employee at least 15
calendar days to return this form to the employer.
(This section must be completed before SectionII can be completed by a health care provider.)
Part A: EMPLOYEE INFORMATION
Name and address of employer (this is the employer of the employee requesting leave to care for a veteran):
__________________________________________________________________________________________________
Name of employee requesting leave to care for a veteran:
_________________________________________________________________________________________________
First Middle Last
Name of veteran (for whom employee is requesting leave):
__________________________________________________________________________________________________
FirstMiddleLast
Relationship of employee to veteran:
Spouse
ParentSon DaughterNext of Kin(please spec ify relati onshi p):
Page 1 CONTINUED ON NEXT PAGEForm WH-385-V Revised May 2015
Part B: VETERAN INFORMATION
(1)Date of the veteran’sdischarge:
_____________________________________________________________________________________
(2)Was the veteran dishonorablydischarged or released from the Armed Forces (including the National Guard
or Reserves)?Yes
No
(3)Please provide the veteran’s military branch, rank and unit at the time of discharge:
___________________________________________________________________________________________
(4)Is the veteran receiving medical treatment, recuperation, or therapy for an injury or illness?
Yes
No
Part C: CARE TO BE PROVIDED TO THE VETERAN
Describe the care to be prov ided to the veteran and an estimate of the leave needed to provide the care:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Page 2 CONTINUED ON NEXT PAGEForm WH-385-V Revised May 2015
SECTION II: For completion by: (1)a United States Department of Defense (“DOD”) healthcare provider; (2) a
United States Department of Veterans Affairs (“VA”) health care provider; (3) a DOD TRICARE network
authorized private health care provider; (4) a DOD non-network TRICARE authorized private health care
provider; or (5) a health care provider as defined in29 CFR 825.125.
INSTRUCTIONS to the HEALTH CARE PROVIDER:
The employee named in Sec tion I has requested leave under the
military caregiver leave provision of the FMLAto care for a family member who is a veteran. For purposes of FMLA military
caregiverleave, a se rious inj ury or illness means an inj ury or i llnes s incurred by the servicemember i n the line of dut y on act ive duty
in the Armed Forces (or that existed before the beginning of the servicemember’s active dut y 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:
(i) acontinuation 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
(ii) 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 pr e c ipitating the nee d for military caregiver leave; or
(iii) a ph ysical or mental condition that substantia lly impairsthe covered veteran’s ability to secure or follow a substantially
gainful occupation b y reason of a disability or d isabilitiesre la te d to military service, or would do so absent treatment; or
(iv) an injury, i ncluding a psychol ogica l injur y, on the basisof whic h the covered veteranhas beenenrolledin the
Department of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
A complete and sufficient certification to support a request for FMLA military caregiverleave due to a covered veteran’s serious
injury or illness includes wr itten documentation co nfirming that the veteran’s injury or i llnes s was i ncurred in the line of duty on
acti ve duty or exist ed before the beginning of the veteran’sactive duty and was aggravated by servicein the line o f duty on active
duty, and that the vete ran is u ndergoing t reatment, recuperation, or therapyfor such injury or i llness by a he alth care provider l isted
above. 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
exa mination 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. Limit your responses to the veteran’s condition for which the employee is
seeking leave. Do not provide information about genetic tests, as defined in 29 CFR 1635.3(f), or genetic services, as defined in 29
CFR 1635.3(e).
(Please ensure that Section I has been completed before completing this section. Please be sure to sign the form on the
last pageand return this form to the employee requesting leave (See Section I, Part A above).
DO NOT SEND THE
COMPLETED FORMTO THE WAGE AND HOUR DIVISION.
)
Part A: HEALTH CARE PROVIDER INFORMATION
Health care provider’s name and business address:
__________________________________________________________________________________________________
Telephone: ( ) _______________ Fax: ( ) _______________ _ Em ail: ____________________ __________________
Type of Practice/Medical Specialty: ____________________________________________________________________
Please indicate if you are:
a DOD health care provider
a VA health care provider
a DOD TRICARE network authorized private health care provider
a DOD non-network TRICARE authorized private health care provider
other health care provider
Page 3 CONTINUED ON NEXT PAGEForm WH-385-V Revised May 2015
PART B: MEDICAL STATUS
N
ote: If you are unable to make certain of the military-related determinations contained in Part B, you are permitted to
rely upon determinations from an authorized DOD representative (such as, DOD Recovery Care Coordinator) or an
authorized VA repr esen tati v e.
(1
) The Veteran ’s med ical condition 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.
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 disabilitiesrelate d to military servic e, or would do
so absent treatment.
An inj ury, including a ps ycho logical injury, on the basiso f whic h the covered veteran is enrolledin the Department
of Veterans’ Affairs Program of Comprehensive Assistance for Family Caregivers.
None of the above.
(2
) Is theveteran being treated for a condition which was incurred or aggravated by service in theline of duty on
active duty in the ArmedForces? Yes
No
(3
) Approximate date condition commenced: _________________________________________________________
(4
) Probable duration of condition and/or need for care: ________________________________________________
(5
) Is the veteran undergoing medical treatment, recuperation, or therapy for th is co n d it ion ? Yes
No
I
f yes, please describe medical treatment, recuperat ion or therapy:
_________
____________________________________________________________________________________
PART C: VETERAN’S NEED FOR CARE BY FAMILY MEMBER
“N
eed for care” encompasses both physical and psychological care. It includes situations where, for example, due to his
or her serious injury or illness, the veteran is unable to care for his or her own basic medical, hygienic, or nutritional needs
or safety, or is unable to transport him or herself 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.
(
1)Will the veteran need care for a single continuous period of time, including any time for treatment and recovery?
Yes
No
If yes, estimate the beginning and ending dates for this period of time: ____________________________________
(2
) Will the veteran require periodic follow-up treatment appointments? Yes
No
I
f yes, estimate the treatment schedule: _____________________________________________________________
Page 4 CONTINUED ON NEXT PAGEForm WH-385-V Revised May 2015
(3
) Is there a medical necessity for the veteran to have periodic care for these follow-up treatment appointments?
Yes
No
(4) Is there a medical necessity for the veteran to have periodic care for other than scheduled follow-up treatment
appointments (e.g., episodic flare-ups of medical condition)? Yes
No
I
f yes, please estimate the frequency and duration of the periodic care:
_________
____________________________________________________________________________________
_________
____________________________________________________________________________________
S
ignature of Health Care Provider: ________________________________ Date: _______________________
PAPERWORK REDUCT ION ACT NOTICE AND PUBLIC BURDEN S TATEMENT
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
CFR 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 th at it will take an average of 20 minutes for respondents to co mpl ete this collection of information, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing t he
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, RoomS-35 02, 20 0
Constitution Ave., NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORMTO THE WAGE AND HOUR DIVISION;
RETURN IT TO THE EMPLOYEE REQUESTING LEAVE (As shown in Section I, Part “A” above).
Page 5 Form WH-385-V Revised May 2015
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