Certification of Health Care Provider for                                              U.S. Department of Labor 
Employee’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 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. 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 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.)

(4) Employee's job title:                                                                      Job description        is /                        is not attached. 

Employee’s regular work schedule: 

Statement of the employee’s essential job functions: 

    (The essential functions of the employee's position are determined with reference to the position the employee held at the time the employee notified the 
    employer of the need for leave or the leave started, whichever is earlier.) 

SECTION II - HEALTH CARE PROVIDER 

Please provide your contact information, complete all relevant parts of this Section, and sign the form. Your patient has requested leave under 
the FMLA. 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 due to the serious health condition of the employee. 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 on page 4. 
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. 

Page 1 of 4                                                                                        Form WH-380-E, Revised June 2020 

  Employee Name: 
 
  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(s) 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) State the approximate date the condition started or will start:                                                          (mm/dd/yyyy)  
 
  (2) Provide your best estimate of how long the condition lasted or will last: 
 
  (3) 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. 

  Page 2 of 4                                                                                 Form WH-380-E, Revised June 2020 

Employee Name: 

(4) 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 FMLA coverage. 

(5) 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): 

(6) 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) 

(7) Due to the condition, it is medically necessary for the employee to work a reduced schedule.
Provide your best estimate of the reduced schedule the employee is able to work. From                              (mm/dd/yyyy)  
to                     (mm/dd/yyyy)     the employee is able to work: (e.g., 5 hours/day, up to 25 hours a week) 

(8) 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. 
(9) Due to the condition, it ( was /    is /      will be) medically necessary for the employee to be absent from work 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. 

Page 3 of 4                                                                                             Form WH-380-E, Revised June 2020 

Employee Name: 

PART C: Essential Job Functions 
If provided, the information in Section I question #4 may be used to answer this question. If the employer fails to provide a statement of the 
employee’s essential functions or a job description, answer these questions based upon the employee’s own description of the  essential job 
functions. An employee who must be absent from work to receive medical treatment(s), such as scheduled medical visits, for a serious health 
condition is considered to be not able to perform the essential job functions of the position during the absence for treatment(s). 
(10) Due to the condition, the employee ( was not able / is not able / will not be able)  to perform one or more of the 
essential job function(s). Identify at least one essential job function the employee is not able to perform: 

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-E, Revised June 2020