The Form WH-380-E, known as the Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition, plays a crucial role under the Family and Medical Leave Act (FMLA). It is a document that employers may require from employees seeking FMLA leave due to a serious health condition, to validate the need for such leave through medical certification from the health care provider. Employers are given a guideline to provide at least 15 days for the employee to submit this certification, and failure to provide a completed form can lead to the denial of the FMLA leave request. To ensure your rights under FMLA are protected, complete and submit the WH-380-E form by clicking the button below.
In the landscape of employment law, the WH-380-E form plays a pivotal role under the umbrella of the Family and Medical Leave Act (FMLA). Specifically designed for employees experiencing serious health conditions that necessitate taking leave from work, this form acts as a bridge between healthcare providers and employers, ensuring that the employee's request for FMLA leave is substantiated by medical facts. At its core, the WH-380-E form, officially titled "Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition," serves as a certification issued by the health care provider to validate the employee's health condition. The U.S. Department of Labor outlines specific guidelines on the form, emphasizing confidentiality and the careful handling of medical records under the FMLA. Employers must give employees a minimum of 15 calendar days to submit the completed certification and are restricted in the amount of medical information they can request. This safeguard maintains the privacy and dignity of the employee while ensuring the employer receives the necessary information to process FMLA leave requests. Crucial to navigating the FMLA process, the WH-380-E form upholds the act's intent to balance the demands of the workplace with the needs of families.
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: 6/30/2023
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 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.
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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.
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(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.
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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:
OTwo 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,
OAt 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.
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Filling out the WH-380-E form is necessary for employees seeking FMLA leave due to a serious health condition. By completing this form correctly, employees can provide their employers with the required medical certification. To ensure the process is smooth and straightforward, here’s a step-by-step guide on how to fill out the form.
Once the WH-380-E form is fully completed and signed by the health care provider, it should be returned to the employee so they can provide it to their employer. This form is a critical component of the FMLA leave process, ensuring that employees have the necessary documentation for their leave request due to a serious health condition.
The WH-380-E form, known as the Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition, is a document that employers may require from an employee who seeks to use FMLA (Family and Medical Leave Act) leave due to their own serious health condition. This certification, provided by the employee's health care provider, serves to verify the medical condition and the necessity for taking FMLA leave. It ensures that the leave request is based on valid medical reasons as defined under the FMLA.
The form is divided into several sections that must be filled out by either the employee, employer, or the health care provider. The initial section pertains to the employer's and employee's details, which can be filled out by either party. The bulk of the form, however, is designated for completion by the health care provider, who must enter specific medical details about the employee's condition, including the nature, duration, and necessary treatment or accommodations. This includes information on whether the condition requires inpatient care, continued treatment, or results in incapacity. The health care provider must then sign and date the form, attesting to the accuracy of the provided information.
The employer must grant the employee at least 15 calendar days to submit the completed WH-380-E form after it has been requested. This timeframe is designed to provide the employee sufficient time to acquire the necessary medical certification from their health care provider. If the employee fails to submit the form within this period, and does not make a diligent, good faith effort to comply despite this failure, their request for FMLA leave may be denied.
Yes, the FMLA has specific regulations to maintain the confidentiality of medical records and information. Employers are required to treat all documents related to medical certifications, recertifications, or medical histories of employees, obtained for FMLA purposes, as confidential medical records. These should be stored in separate files from the usual personnel files. Moreover, compliance with the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act dictates further protections concerning the handling, access, and disclosure of these records.
Filling out the WH-380-E form, a Certification of Health Care Provider for a U.S. Department of Labor Employee’s Serious Health Condition under the Family and Medical Leave Act (FMLA), can sometimes be confusing. People often make mistakes that could delay the processing of their FMLA leave request. Understanding these common errors can help ensure that the form is completed correctly and efficiently.
Not providing specific dates related to the onset of the condition, expected duration, treatment schedules, or the period of incapacity. Vague or incomplete date information can lead to requests being questioned or not processed timely.
Leaving sections blank that require a detailed description of the medical condition(s), symptoms, diagnosis, and any required or ongoing treatment. Inadequate details can lead to an incomplete assessment of the FMLA eligibility.
Failure to indicate the necessity of intermittent leave or a reduced schedule when the condition results in episodic flare-ups. This oversight can affect the approval of flexible leave arrangements.
Omitting contact information of the health care provider or not ensuring the form is signed by the provider. This missing information can delay verification processes or result in a denial due to lack of authentication.
Overlooking the requirement to describe the employee's essential job functions and whether the employee is unable to perform these due to their condition. This can cause misunderstandings about the leave's impact on job performance.
Submitting the form to the wrong place, such as directly to the Department of Labor instead of returning it to the employer or employee, as instructed. Misdirected forms can lead to significant delays in processing the FMLA leave request.
In summary, careful attention to detail when filling out the WH-380-E form is crucial. This includes providing complete medical information, ensuring all parts of the form are filled out accurately, and submitting the form to the correct recipient. Avoiding these common mistakes can help streamline the FMLA leave request process and support employees through their time of need.
The Family and Medical Leave Act (FMLA) requires certain documents for employees seeking leave due to a serious health condition. The WH-380-E form is a vital piece of documentation in this process, serving as the certification from a health care provider confirming the employee's need for leave due to their condition. However, this form is often just a part of a broader suite of documentation required to navigate the FMLA leave process effectively. Various other forms and documents play crucial roles in ensuring both the employee and employer meet their respective obligations under the FMLA.
Understanding and utilizing these forms correctly is crucial for both employers and employees to ensure compliance with FMLA requirements. Each form serves a specific purpose in the FMLA leave process, from certifying the need for leave due to a medical condition, to managing the administrative aspects of leave designation and usage. Employers and employees alike must familiarize themselves with these forms to navigate the FMLA leave process efficiently and compliantly.
The WH-380-E form, or the Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition under the Family and Medical Leave Act (FMLA), is an essential document for employees seeking FMLA leave due to a personal health condition. Its structure, purpose, and requirements share similarities with various other forms and documents. Let’s explore seven documents that resemble the WH-380-E form in various respects:
Each of these documents, while serving unique purposes, shares a foundational requirement with the WH-380-E form: the need for detailed, sometimes sensitive, medical information to support an individual's request for leave or accommodations. Understanding the nuances of each can empower employees to more effectively navigate their rights and responsibilities under various laws and regulations.
When filling out the WH-380-E form for FMLA leave due to a serious health condition, it's important to understand what you should and shouldn't do to ensure the process goes smoothly. Here are some pointers to consider:
Following these guidelines can help ensure that your FMLA leave request is processed efficiently and in compliance with the regulations. Remember, this form is a critical component of securing your rights under the FMLA, so taking the time to complete it correctly is crucial.
The WH-380-E form is an essential document for employees seeking leave under the Family and Medical Leave Act (FMLA) due to a serious health condition. However, several misconceptions surround its use and requirements. Understanding these nuances can ensure employees and employers navigate FMLA leave more effectively.
Only the Employee Can Complete Section I: It is often misunderstood that the initiation of the form, specifically Section I, is the sole responsibility of the employee. However, either the employee or the employer may complete this section, facilitating the process and allowing for greater collaboration from the start.
The Form Must Be Sent to the Department of Labor: A common misconception is that the completed WH-380-E form needs to be sent to the Department of Labor (DOL) for processing. The instructions explicitly state that the completed form should not be sent to the DOL but instead returned to the patient, thereby ensuring confidentiality and direct communication between employer and employee.
There Is No Deadline for Submission: The assumption that there is flexibility in when the WH-380-E form can be submitted is incorrect. The employer must allow at least 15 calendar days for the employee to return the completed certification. This timeframe ensures a balance between the need for prompt decision-making regarding leave and giving employees sufficient time to gather and provide the necessary medical certification.
Any Information Beyond the Serious Health Condition Is Required: Employers and employees sometimes think additional medical information beyond that which pertains to the specific serious health condition being claimed can be requested and provided. The form, however, limits responses to the condition for which the employee seeks FMLA leave, protecting the employee’s privacy regarding unrelated medical issues.
Form WH-380-E Covers Leave for Any Purpose: There’s a misconception that the WH-380-E form is applicable for FMLA leave under any circumstance, including bonding with a healthy newborn. This form is specifically for leave requests due to the employee’s serious health condition. FMLA leave for other reasons, such as bonding with a newborn, has separate documentation requirements.
Diagnosis Disclosure Is Mandatory: A significant area of confusion involves the disclosure of the diagnosis. While the form requests detailed information about the health condition and any incapacity, it does not mandate the disclosure of the diagnosis. This respects patient privacy while still conveying the necessary information about how the condition affects the employee's ability to work.
Dispelling these misconceptions is crucial for both employees seeking to utilize their FMLA rights and employers managing leave requests. Proper understanding ensures that the WH-380-E form is used appropriately, facilitating a smoother process for all parties involved.
Understanding the WH-380-E form is essential for employees needing leave due to their own serious health conditions under the Family and Medical Leave Act (FMLA). Below are key takeaways to guide you through filling out and using this form correctly:
By adhering to these guidelines, employees and employers can navigate the FMLA leave process more smoothly, ensuring that the necessary time off is granted for serious health conditions without unnecessary complications.
Fl 120 - Outlines the conditions under which the landlord can transfer the security deposit and requires tenant's acknowledgment for such transfers.
Living Will California - This document enables Californians to appoint a health care agent who will make decisions on their behalf based on the outlined instructions.
Sr13 Form - Designed to facilitate accurate accident reporting to the Bureau of Safety Responsibility in Georgia.