What is Form WH-380-E?
Form WH-380-E is the Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act (FMLA). Employers may require employees to provide this completed certification when requesting FMLA leave for their own serious health condition.
Who Uses This Form?
- Employees requesting FMLA leave for their own serious health condition provide this form to their healthcare provider for completion
- Healthcare providers (physicians, nurse practitioners, physician assistants, etc.) complete the medical portions of the form
- Employers review the certification to determine FMLA eligibility and leave duration
Sections of the Form
Section I — Employee Information
- Completed by the employer or employee
- Employee's job description and essential job functions
- Nature of the leave requested (continuous, intermittent, or reduced schedule)
- Statement from employer about FMLA rights and obligations
Section II — Health Care Provider Information
- Provider's name, address, type of practice/specialization
- Patient's diagnosis and ICD code
- Date condition commenced and probable duration
- Whether condition is a chronic or permanent long-term condition
Section III — Medical Facts
- Description of the serious health condition
- Whether the patient requires overnight hospitalization
- Whether the condition is likely to cause episodic flare-ups
- Estimated frequency and duration of incapacity episodes
Section IV — Care Regimen
- Medications, treatments, and referrals required
- Whether employee is unable to perform any job functions
- Whether employee needs intermittent or reduced schedule leave
- Duration of need for leave
FMLA Eligibility Requirements
To be eligible for FMLA leave, an employee must:
- Work for a covered employer (50+ employees within 75 miles)
- Have worked for the employer for at least 12 months
- Have worked at least 1,250 hours in the past 12 months
Employer Deadlines
- Employer must provide the WH-380-E form within 5 business days of learning of the need for FMLA leave
- Employee has 15 calendar days to return the completed certification
- Employer must notify the employee of FMLA designation within 5 business days of receiving completed certification
Frequently Asked Questions
Can an employer contact the healthcare provider directly?
Limited contact is permitted — only to authenticate or clarify the certification. Employers may not ask for additional information beyond what is on the form and cannot request the complete medical record.
Can an employer require a second opinion?
Yes. If the employer has reason to doubt the initial certification, they may require the employee to obtain a second opinion from a provider of their choosing (at the employer's expense).
What is a "serious health condition" for FMLA purposes?
An illness, injury, impairment, or physical/mental condition that involves inpatient care, or continuing treatment by a healthcare provider resulting in incapacity of more than 3 consecutive days, pregnancy, a chronic condition, permanent/long-term condition, or restorative surgery after treatment.
Is a different form used for a family member's health condition?
Yes — use Form WH-380-F for certification related to a family member's (spouse, child, or parent) serious health condition.