WH-380-F Summary of edits

Changes to form WH-380-F, Certification for Family Member’s Serious Health Condition

General

1. Added color to WHD logo and section headers

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

3. Reorganized order of information requested 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

12. Added instruction that either the employer or employee may complete the section

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

14. Added entry for the employee’s name

15. Removed “contact” from employer name line

16. Added date line and return by date

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

Section II – Employee

14. Added checkbox options for family member relationship

15. Added option to indicate child over age 18

16. Removed request for date of birth of child

17. Added definition of spouse and explanation of in loco parentis

18. Split question about care to be provided and amount of leave needed

19. Added check box options for the care the employee will provide to the family member

20. Added option for reduced work schedule information

Section III – Health Care Provider

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

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

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

17. Added entry for e-mail contact information

Section III, Part A: Medical Information

14. Added checkbox options for medical conditions

15. Added examples to the medical conditions

16. Added checkbox option for “None of the above”

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

Section III, Part B: Amount of Leave Needed

14. Added check boxes

15. Added examples

16. Changed format, if treatment needed

17. Changed format, if reduced leave schedule needed

18. Changed format, if intermittent leave needed

19. Deleted duplicated questions about the medical necessity of care

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