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.

DOL Form WH-380-E: FMLA Certification for Employee's Health Condition