SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies.

 

Employer name and contact: _____________________________________________________________

 

Employee’s job title: _______________________ Regular work schedule: _______________________

 

Employee’s essential job functions: ______________________________________________________

 

Check if job description is attached: _____

 

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).

Your name: _______________________________________________________________________________
                        First                                         Middle                                      Last

 

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page.

 

Provider’s name and business address: ____________________________________________________

 

Type of practice / Medical specialty: _____________________________________________________

 

Telephone: (________)____________________________Fax:(_________)_______________________

 

 

PART A: MEDICAL FACTS                                                                                                                                                                                                                                   

1. Approximate date condition commenced: ________________________

 

Probable duration of condition: __________________________________________________________

 

Mark below as applicable:

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? ___No ___Yes. If so, dates of admission:

Date(s) you treated the patient for condition:

____________________________________________________________________________________

 

Will the patient need to have treatment visits at least twice per year due to the condition? ___No ___ Yes.

 

Was medication, other than over-the-counter medication, prescribed? ___No ___Yes.

 

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? ____No Yes____. If so, state the nature of such treatments and expected duration of treatment:

 

2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ________________

 

3. Use the information provided by the employer in Section I to answer this question. If the employer fails        to provide a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s own description of his/her job functions.

 

Is the employee unable to perform any of his/her job functions due to the condition: ____ No ____ Yes.

 

If so, identify the job functions the employee is unable to perform:

 

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

 

 

PART B: AMOUNT OF LEAVE NEEDED

5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery?

____ No ____ Yes.

            If so, estimate the beginning and ending dates for the period of incapacity: __________________

 

6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee’s medical condition?

___No ___Yes.

 

            If so, are the treatments or the reduced number of hours of work medically necessary?

             ___No ___Yes.

 

            Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

____________________________________________________________________________

            Estimate the part-time or reduced work schedule the employee needs, if any:

            _________hour(s) per day; ________ days per week from ____________through ____________

 

7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? ____ No ____ Yes.

 

            Is it medically necessary for the employee to be absent from work during the flare-ups?   ____ No ____ Yes. If so, explain:

______________________________________________________________________________

______________________________________________________________________________

 

            Based upon the patient’s medical history and your knowledge of the medical condition, estimate        the frequency of flare-ups and the duration of related incapacity that the patient may have over         the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):

Frequency: _____ times per       _____ week(s) month(s) _____

 

            Duration: _____ hours or ___ day(s) per episode

 

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

_____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

 

____________________________________________________________________________________
Signature of Health Care Provider                                                                      Date

 

 

 

 

 

 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

                                                                                                                               Form WH-380-E Revised January 2009

 

Notice to the EMPLOYER INSTRUCTIONS to the EMPLOYER:  The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a serious injury or illness of a covered servicemember to submit a certification providing sufficient facts to support the request for leave.  Your response is voluntary.  While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310.  Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees or employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies.

 

SECTION I:  For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom the Employee Is Requesting Leave INSTRUCTIONS to the EMPLOYEE or COVERED SERVICEMEMBER:  Please complete Section I before having Section II completed.  The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a serious injury or illness of a covered servicemember.  If requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave.  29 U.S.C. §§ 2613, 2614(c)(3).  Failure to do so may result in a denial of an employee’s FMLA request.  29 C.F.R. § 825.310(f).  The employer must give an employee at least 15 calendar days to return this form to the employer.

 

SECTION II:  For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either:  (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2)  a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider INSTRUCTIONS to the HEALTH CARE PROVIDER:   The employee listed on Page 2 has requested leave under the FMLA to care for a family member who is a member of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness.  For purposes of FMLA leave, a serious injury or illness is one that was incurred in the line of duty on active duty that may render the servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating.

A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember’s serious injury or illness includes written documentation confirming that the covered servicemember’s injury or illness was incurred in the line of duty on active duty and that the covered servicemember is undergoing treatment for such injury or illness by a health care provider listed above.  Answer, fully and completely, all applicable parts.  Several questions seek a response as to the frequency or duration of a condition, treatment, etc.  Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient.  Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage.  Limit your responses to the condition for which the employee is seeking leave.

 

SECTION I:  For Completion by the EMPLOYEE and /or the COVERED SERVICE MEMBER for whom the Employee Is Requesting Leave:  (This section must be completed first before any of the below sections can be completed by a health care provider.)

PART A:  EMPLOYEE INFORMATION

Name and Address of Employer (this is the employer of the employee requesting leave to care for covered servicemember):

______________________________________________________________________________

 

Name of Employee Requesting Leave to Care for Covered Servicemember:

______________________________________________________________________________
                      First                                       Middle                                     Last

 

Name of Covered Servicemember (for whom employee is requesting leave to care):

______________________________________________________________________________
                      First                                       Middle                                     Last

 

Relationship of Employee to Covered Servicemember Requesting Leave to Care:

         Spouse        Parent        Son             Daughter       Next of Kin

 

PART B:  COVERED SERVICE MEMBER INFORMATION

 

1.       Is the covered service member a current member of the Regular Armed Forces, the    National Guard or Reserves?      Yes       No

          If “yes,” please provide the covered service member’s military branch, rank and unit currently assigned to:  ______________________________________________________

 

Is the covered service member assigned to a military medical treatment facility as an outpatient or to a  unit established for the purpose of providing command control of members of the Armed Forces receiving medical care as outpatients (such as a medical hold or warrior transition unit)?  _____ Yes  _____ No.  If “yes, please provide the name of the medical treatment facility or unit:  ________________________________________

 

2.       Is the covered service member on the Temporary Disability Retired List (TDRL)?          Yes     No. 

 

PART C:  CARE TO BE PROVIDED TO THE COVERED SERVICE MEMBER

 

Describe the care to be provided to the covered service member and an estimate of the leave needed to provide the care: 

______________________________________________________________________________

______________________________________________________________________________

 

SECTION II:  For Completion by a United States Department of Defense (“DOD”) Health Care Provider or Health Care Provider who is either:  (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider. If you are unable to make certain of the military-related determinations contained below in Part B, you are permitted to rely upon determinations from an authorized DOD representative (such as a DOD recovery care coordinator).  (Please ensure that Section I above has been completed before completing this section.)  Please be sure to sign the form on the last page.

 

PART A:  HEALTH CARE PROVIDER INFORMATION

Health Care Provider’s Name and Business Address:  

_________________________________________________________________________________________

 

Type of Practice/Medical Specialty:  ___________________________________________________________

 

Please state whether you are either:  (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized private health care provider:  __________________________________________________________________

 

Telephone: (     ) ________________   Fax: (     ) ________________   Email: __________________________

 

PART B:  MEDICAL STATUS

 

1.       Covered servicemember’s medical condition is classified as (check one of the appropriate boxes):

 

           (VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently endangered.  Family members are requested at bedside immediately.  (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers.)         

           (SI) Seriously Ill/Injured – Illness/injury is of such severity that there is cause for immediate concern, but there is no imminent danger to life.  Family members are requested at bedside.  (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers.)

           OTHER Ill/Injured – A serious injury or illness that may render the service member medically unfit to perform the duties of the member’s office, grade, rank, or rating.

           NONE OF THE ABOVE (Note to Employee:  If this box is checked, you may still be eligible to take leave to care for a covered family member with a “serious health condition” under § 825.113 of the       FMLA.  If such leave is requested, you may be required to complete DOL FORM WH-380 or an employer-provided form seeking the same information.)

2.       Was the condition for which the covered service member is being treated incurred in line of duty on active duty in the Armed Forces?   Yes    No

 

3.       Approximate date condition commenced:  _______________________________________

                                                                                                                        

4.       Probably duration of condition and/or need for care:  ______________________________                                 

 

 

5.       Is the covered service member undergoing medical treatment, recuperation, or therapy?    

    Yes     No

 

                             If “yes,” please describe medical treatment, recuperation or therapy:          

_________________________________________________________________________

 

PART C:  COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER

 

1.       Will  the  covered  servicemember need care for a single continuous period  of  time, including any time for treatment and recovery?

    Yes     No

          If “yes,” estimate the beginning and ending dates for this period of time: _________________________

 

2.       Will the covered service member require periodic follow-up treatment appointments? 

 

    Yes     No

            If  “yes.” Estimate the treatment schedule:  _________________________________

 

 

3.       Is there a medical necessity for the covered service member to have periodic care for these follow-up treatment appointments?  

    Yes     No

 

 

 

4.       Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled follow-up treatment appointments (e.g., episodic flare-ups of medical condition)? 

    Yes     No     If “yes,” please estimate the frequency and duration of the periodic care:  __________________________________________________________________________________________

 

__________________________________________________________________________________________

 

 

 

______________________________________     _____________________________________
Signature of Health Care Provider                       Date

 

         

 

 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If  submitted,  it  is  mandatory  for  employers  to  retain  a  copy  of  this  disclosure  in  their records for 3 years in accordance with  29 U.S.C.  § 2616; 29 C.F.R. § 825.500.  Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.  The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC   20210.  DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

 

SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical certification issued by the health care provider of the covered family member. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies.

 

 Employer name and contact: _______________________________________________________________________

_______________________________________________________________________________________________

 

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.

 

 Your name: ____________________________________________________________________________________
                        First                                         Middle                                      Last

 

 Name of family member for whom you will provide care:________________________________________________
                                                                                      First                     Middle                      Last

 Relationship of family member to you: ______________________________________________________________

 

 If family member is your son or daughter, date of birth:__________________________________________________

 

 Describe care you will provide to your family member and estimate leave needed to provide care:

­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

 

_____________________________________________                    ________________________________________
 Employee Signature                                                                       Date

 

 

SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page.

 

Provider’s name and business address:________________________________________________________________

 

Type of practice / Medical specialty: _________________________________________________________________

 

Telephone: (________)____________________________ Fax:(_________)__________________________________

 

PART A: MEDICAL FACTS

1. Approximate date condition commenced: ____________________________________________________________ Probable duration of condition: ____________________________________________________________________

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?

___No ___Yes. If so, dates of admission: ______________________________________________________________

 

Date(s) you treated the patient for condition: ___________________________________________________________

 

Was medication, other than over-the-counter medication, prescribed? No ______Yes.

 

Will the patient need to have treatment visits at least twice per year due to the condition? ___No ____ Yes.

 

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?

____ No ____Yes. If so, state the nature of such treatments and expected duration of treatment:  

_______________________________________________________________________________________________

_______________________________________________________________________________________________

 

2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ___________________________

 

3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

 

 

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care:

 

4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? ___No ___Yes.

 

    Estimate the beginning and ending dates for the period of incapacity: ______________________________________

 

    During this time, will the patient need care? __ No __ Yes.

 

    Explain the care needed by the patient and why such care is medically necessary: _____________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

 

5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes.

     Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

 

­­­­­­­­­­­­­­­­­­­­_________________________________________________________________________________________________

 

Explain the care needed by the patient, and why such care is medically necessary: _______________________________

 

_________________________________________________________________________________________________

 

6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?

     __ No __ Yes.

 

     Estimate the hours the patient needs care on an intermittent basis, if any:

 

_________ hour(s) per day; ________ days per week              from _________________ through __________________

 

Explain the care needed by the patient, and why such care is medically necessary: _______________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

 

7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily     activities? ____No ____Yes.

    

     Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):

 

     Frequency: _____ times per _____ week(s) _____ month(s)

 

     Duration: _____ hours or ___ day(s) per episode

 

     Does the patient need care during these flare-ups? ____ No ____ Yes.

 

     Explain the care needed by the patient, and why such care is medically necessary: _____________________________

  _______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________

 

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.  

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

 

_______________________________________________ _____________________________________________

Signature of Health Care Provider                                          Date

 

 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.