___________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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
click to sign
signature
click to edit