Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act

Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act
SECTION I – EMPLOYEE/EMPLOYER
(1) Employee name
(2) Employer name
Date certification requested

MonthDayYear
Date
(3)The medical certification must be returned by (Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s diligent, good faith efforts.)

MonthDayYear
Date FMLA must be returned by
(4)Employee’s job title
Is job description attached?

YesNo
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
Employee Name
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

MonthDayYear
Date
(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.
The patient has been/is expected to be admitted for an overnight stay in a hospital, hospice, or residential medical care facility

has beenis expected to be
The patient has been/is expected to be admitted for an overnight stay in a hospital, hospice, or residential medical care facility beginning on:

MonthDayYear
Date
The patient has been/is expected to be admitted for an overnight stay in a hospital, hospice, or residential medical care facility ending on:

MonthDayYear
Date
Due to the condition, the patient has been/is expected to be incapacitated for more than three consecutive, full calendar days

has beenis expected to be
Due to the condition, the patient has been/is expected to be incapacitated for more than three consecutive, full calendar days beginning on

MonthDayYear
Date
Due to the condition, the patient has been/is expected to be incapacitated for more than three consecutive, full calendar days ending on

MonthDayYear
Date
The patient was/will be seen on the following dates

waswill be
dates:
The condition has/has not also resulted in a course of continuing treatment under the supervision of a healthcare provieder

hashas not
Pregnancy: The condition is pregnancy. List the expected delivery date

MonthDayYear
Date
Select one of the following

Chronic ConditionsPermanent of Long Term ConditionsConditions requiring Multiple TreatmentsNone of the above
Employee Name
If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks FMLA leave
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.
Due to the condtion, the patient has/will have planned medical treatment(s)

will behad
The patient will have planned medical treamtment on the following date(s)
Due to the condition, the patient was/will be referred to other health care provider(s) for evaluation or treament(s)

waswill be
State the nature of such treatments: (e.g. cardiologist, physical therapy)
Provide your best estimate of the beginning date

MonthDayYear
Date
and end date

MonthDayYear
Date
Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery (e.g. 3 days/week)
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

MonthDayYear
Date
to

MonthDayYear
Date
The employee is able to work: (e.g., 5 hours/day, up to 25 hours a week)
Due to the condition, the patient was/will be incapacitated for a continuous period of time, including any time for treament(s) and/or recovery

waswill be
Provide your best estimate of the beginning date

MonthDayYear
Date
and end date

MonthDayYear
Date
Due to the condition it will/is/will be necessary for the employee to be absent from work on an intermittent basis(periodically), including for any episodes of incapacity (i.e., episodic fare-ups.)

williswill be
Provide your best estimate of how often and how long the episodes of incapacity will likely last. Over the next 6 months, episodes of incapacity are estimated to occur how many times per day/week/month
per day/week/month

dayweekmonth
they are likely to last approximately (hours/days) per episode
hours/days

hoursdays
Employee Name
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).
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 functions.

was not ableis not ablewill not be able
Identify at least one essential job function the employee is not able to perform
Signature of Health Care Provider*

Clear
Date

MonthDayYear
Date
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.

Form WH-380-E, Revised June 2020
Should be Empty:

Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act

SECTION I – EMPLOYEE/EMPLOYER

SECTION II -HEALTH CARE PROVIDER

PART A: Medical Information

PART B: Amount of Leave Needed

PART C: Essential Job Functions

Inpatient Care

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT