FMLA: Forms | U.S. Department of Labor
Summary: Form WH-380-E is the official U.S. Department of Labor certification form used by health care providers to verify an employee's serious health condition for FMLA leave eligibility.
This document is the U.S. Department of Labor's Form WH-380-E, used to certify that an employee has a serious health condition qualifying for leave under the Family and Medical Leave Act (FMLA). The form is divided into three sections: Section I for employer-provided job details, Section II for the health care provider's medical assessment, and Part C regarding essential job functions. It includes specific instructions for providers on documenting the nature of the condition, the duration of incapacity, and the necessity of intermittent or reduced-schedule leave. The form also provides definitions of 'serious health condition' and guidance on privacy and record-keeping requirements.
Document outline
1. Section I: Employer Information (Employee details, job description, essential functions) 2. Section II: Health Care Provider Information (Contact details, medical specialty) 3. Part A: Medical Information (Condition onset, duration, and type) 4. Part B: Amount of Leave Needed (Planned treatments, reduced schedule, continuous incapacity, intermittent leave) 5. Part C: Essential Job Functions (Ability to perform job duties) 6. Definitions of a Serious Health Condition (Inpatient care, continuing treatment, chronic conditions, etc.) 7. Paperwork Reduction Act Notice