Certification for Serious Injury or Illness of a                     U.S. Department of Labor 
Current Servicemember for Military Caregiver Leave                 Wage 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:  6/30/2023 

The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave to care for a covered 
servicemember 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. You may not ask the employee 
to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310 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. An employer requiring an employee to submit a 
certification for leave to care for a covered servicemember must accept as sufficient certification invitational travel orders 
(ITOs) or invitational travel authorizations (ITAs) issued to any family member to join an injured or ill servicemember at 
the servicemember’s bedside. An ITO or ITA is sufficient certification for the duration of time specified in the ITO or ITA. 

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 CURRENT SERVICEMEMBER 
Please complete all Parts of Section II before having the servicemember’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 FMLA leave due to a serious injury or illness of a covered servicemember. If requested by your employer, your 
response is required to obtain or retain the benefit of FMLA-protected leave.  

PART A:  EMPLOYEE INFORMATION 
(1) Name of the current servicemember for whom employee is requesting leave:____________________________

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Employee Name: ___________________________________________________________________________________ 

(2) Select your relationship to the current servicemember. You are the current servicemember’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 relationships 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 servicemember’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 servicemember for purposes of FMLA leave, (2) blood relatives granted legal custody
of the servicemember, (3) brothers and sisters, (4) grandparents, (5) aunts and uncles, and (6) first cousins.

PART B: SERVICEMEMBER INFORMATION AND CARE TO BE PROVIDED TO THE SERVICEMEMBER 
(3) The servicemember (  is /   is not ) a current member of the Regular Armed Forces, the National Guard or          
Reserves. If yes, provide the servicemember’s military branch, rank and unit currently assigned to: ______________ 
______________________________________________________________________________________________

(4) The servicemember ( is /     is not) assigned to a military medical treatment facility as an outpatient or to a unit 
established for the purpose of providing command and control of members of the Armed Forces receiving medical 
care as outpatients, such as a medical hold or warrior transition unit. If yes, provide the name of the medical treatment 
facility or unit: __________________________________________________________________________________

(5) The servicemember (  is /   isnot) on the Temporary Disability Retired List (TDRL).

(6) Briefly describe the care you will provide to the servicemember: (Check all that apply)
          Assistance with basic medical, hygienic, nutritional, or safety needs
          Psychological Comfort                      Physical Care
          Transportation                             Other: ___________________________________________

(7) Give your best estimate of the amount of 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 listed at Section I has requested leave under the FMLA to care for a family member who is a current member 
of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or 
therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness. 
Note: For purposes of FMLA leave, a serious injury or illness is one that was incurred in the line of duty on active duty in 
the Armed Forces or that existed before the beginning of the member’s active duty and was aggravated by service in the 
line of duty on active duty in the Armed Forces that may render the servicemember medically unfit to perform the duties of 
the servicemember’s office, grade, rank, or rating. “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 servicemember 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 servicemember who is receiving inpatient or home 

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Employee Name: ___________________________________________________________________________________ 

care. A complete and sufficient certification to support a request for FMLA leave due to a current servicemember’s serious 
injury or illness includes written documentation confirming that the servicemember’s injury or illness was incurred in the 
line of duty on active duty or if not, that the current servicemember’s injury or illness 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 that 
the current servicemember is undergoing treatment for such injury or illness by a health care provider listed above.  

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 C.F.R. § 825.125

PART B:  MEDICAL INFORMATION 
Please provide appropriate medical information of the patient as requested below. Limit your responses to the 
servicemember’s condition for which the employee is seeking leave. If you are unable to make some of the military-related 
determinations contained below, you are permitted to rely upon determinations from an authorized DOD representative, 
such as a DOD recovery care coordinator. 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 servicemember’s injury or illness:  (Select as appropriate)

           Was incurred in the line of duty on active duty.
           Existed before the beginning of the servicemember’s active duty and was
            aggravated by service in the line of duty on active duty.
           None of the above.

(5) The servicemember ( 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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Employee Name: ___________________________________________________________________________________ 

(6)    The current servicemember’s medical condition is classified as:   (Select as appropriate) 
 
        (VSI) Very Seriously Ill/Injured Illness/Injury is of such a severity that life is imminently endangered.  Family 
         members are requested at bedside immediately. Please note this is an internal DOD casualty assistance designation 
         used by DOD healthcare providers. 
         
           (SI) Seriously Ill/Injured Illness/injury is of such severity that there is cause for immediate concern, but there 
            is no imminent danger to life.  Family members are requested at bedside. Please note this is an internal DOD 
            casualty assistance designation used by DOD healthcare providers. 
         
           OTHER Ill/Injured A serious injury or illness that may render the servicemember medically unfit to perform 
            the duties of the member’s office, grade, rank, or rating.  
         
           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 coverage. 
 
 (7)   Due to the condition, the servicemember 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. 
 
(8)    Due to the condition, it is medically necessary for the servicemember to attendplanned medicaltreatment       
       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) 
 
 (9)   Due to the condition, it is medically necessary for the servicemember 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 
       servicemember’s recovery. Provide your best estimate of how often (frequency) and how long (the duration) 
       the intermittent episodes 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, N.W., Washington, D.C. 20210.  
 
   DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN IT TO THE PATIENT. 
 
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