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.

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.

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 ...

Page 1 of 4 Form WH-380-E, Revised June 2020 . U.S. Department of Labor Wage and Hour Division Certification of Health Care Provider for Employee’s Serious Health Condition under the 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: 6/30/2023

2020年8月19日 · WH-384 Certification of Qualifying Exigency For Military Family Leave . WH-385 Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave

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).

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

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 ...