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Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act - WH-380-E Form WH-380-E, Revised June 2020
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under the Family and Medical Leave Act WH-380-E. Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act. U.S. Department of Labor Wage and Hour Division. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT. OMB Control Number: 1235-0003 Expires: 6/30/2026.
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Download the WH-380-E form for certifying an employee's serious health condition. The form is valid for one year from the date of signature and requires the health care provider's signature.
Jul 23, 2020 · WH-380-E — Employee’s Serious Health Condition — For when a leave request is due to the medical condition of the employee. WH-380-F — Family Member’s Serious Health Condition — For when a leave request is due to the medical condition of the employee’s family member.
INSTRUCTIONS to the EMPLOYER: 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.
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
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