Employee’s serious health condition, form WH-380-E - Use when a leave request is due to the medical condition of the employee. Condición de salud grave del empleado, formulario WH-380-E ( Español )

Page 3 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.

WH-380-E: FMLA Certification of Health Care Provider for Employee’s Serious Health Condition. WH-380-E (PDF) WH-380-E Spanish (PDF) WH-380-F: FMLA Certification of Health Care Provider for Family Member’s Serious Health Condition. WH-380-F (PDF) WH-380-F Spanish (PDF) WH-381: FMLA Notice of Eligibility and Rights & Responsibilities. WH-381 ...

The FMLA regulations do not require that the medical certification include a diagnosis. The current FMLA Medical Certification Form for Employee’s Serious Health Condition - WH-380-E permits, but does not require, that the healthcare provider include a diagnosis.

For Download, please click on the Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act Form WH 380 E).

The Department has developed optional forms that can be used for leave for an employee's own serious health condition (WH-380-E) or to care for a family member's serious health condition (WH-380-F). If an employer chooses to use its own forms, it may not require any additional information beyond what is specified in the FMLA and its regulations.

Page of Form WH-380-E, Revised June 2020 . had will . was was was days) day . 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 ...

The US Department of Labor provides official FMLA forms for employers and employees to complete, including the Certification of Health Care Provider of Employee’s Serious Health Condition form, also called form WH 380 E. Employers covered under the law should have these FMLA forms on hand, however a substitute form with the same information ...

Form WH-380-E. Revised . January 2009. Title: Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act) Author: US Department of Labor Wage and Hour Division Subject:

Page 1 Form WH-380-E Revised May 2015 Certification of Health Care Provider for U.S. Department of Labor Wage and Hour Division (Family and Medical Leave Act) DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OMB Control Number: 1235-0003 Expires: 5/31/2018 SECTION I: For Completion by the EMPLOYER