WH-380-E Summary of Edits

Changes to form WH-380-E, Certification for the Employee’s Serious Health Condition

General

1. Added color to WHD logo and section breaks

2. Added opening information with references to the statute, regulations, and WHD FMLA website

3. Reorganized order of information and instructions provided

4. Added line for employee’s name to every page

5. Changed questions to statements to be confirmed by checking a box

6. Aligned text and checkboxes

7. Shortened section titles

8. Added date formatting prompts

9. Renumbered items

10. Bolded selected text for emphasis

11. Removed excess blank lines

12. Added chart explaining the FMLA definition of a serious health condition

13. Rephrasing for plain language, and changes to language to be consistent form to form

Section I: Employer

14. Removed employee section and added instruction to employer section that either the employer or employee may complete

15. Added instruction that certification requests to bond with a child are not permissible

16. Removed “contact” from employer name line

17. Added date line and return by date

18. Added at least 15 calendar days instruction to due date request

19. Moved essential job functions information to employer section

Section II: Health Care Provider

20. Added definitions of serious health condition and incapacity to the instructions

21. Added to instructions that some state or local laws may not allow disclosure of the patient’s private medical information

22. Added to instructions information about certification due date

23. Added instruction to print the health care provider’s name

24. Added entry for e-mail contact information

Section II, Part A: Medical Information

25. Added instructions to the subsection

26. Added check box options for medical conditions

27. Added examples to the medical conditions

28. Added checkbox option for “None of the Above”

29. Reduced number of blank lines for providing additional information

30. Deleted questions about treatment and periods of incapacity duplicated in Part B

Section II, Part B: Amount of Leave Needed

31. Added checkboxes

32. Added examples

33. Changed format, if treatment needed

34. Changed format, if reduced leave schedule needed

35. Changed format, if intermittent leave needed

Section II, Part C: Essential Job Functions

36. Created new Part C: Essential Job Functions

37. Added instructions

38. Added checkbox entry for whether the employee can perform any one or more of the job functions

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