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WH-380-E Certification of Health Care Provider for Employee s Serious Health Condition (Family and Medical Leave Act) To obtain this form go to http://www.dol.gov/esa/whd/forms/WH-380-E.pdf
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How to fill out wh 380 e form
How to fill out the WH 380 E form:
01
Obtain the form: The WH 380 E form, also known as the Certification of Health Care Provider for Employee's Serious Health Condition, can be obtained from the Department of Labor's website or from your employer's HR department.
02
Personal Information: Begin by entering your personal information on the form, including your name, employee ID or social security number, job title, and contact information.
03
Employee's Serious Health Condition: Provide details about the employee's serious health condition, including the nature of the illness or injury, the beginning date when the condition manifested or commenced, and the expected duration of the condition.
04
Treatment Details: Document the health care provider's name, address, and contact information. Indicate if a referral was made for a second opinion or specialist. Include the dates of each treatment or visit.
05
Employee Authentication: The employee must sign and date the form to certify that the information provided is accurate and complete.
06
Health Care Provider Certification: The health care provider who diagnosed or treated the employee's condition must complete their section, including their name, address, signature, and the date of completion. They should also provide a brief description of the employee's medical facts relevant to the certification.
07
Return the Form: Submit the completed form to your employer's HR department within the designated time frame, as required by the Family and Medical Leave Act (FMLA).
Who needs the WH 380 E form?
The WH 380 E form is required for employees who are seeking leave under the provisions of the Family and Medical Leave Act (FMLA). This includes employees who need to take time off work due to their own serious health condition or to care for a family member with a serious health condition.
It is essential for both the employee and employer, as the completed form provides necessary documentation to support the request for FMLA leave and helps ensure compliance with the FMLA regulations.
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What is wh 380 e form?
WH-380-E form is the Certification of Health Care Provider for Employee's Serious Health Condition form that is used for an employee's leave under the Family and Medical Leave Act (FMLA).
Who is required to file wh 380 e form?
Employers are required to have their employees complete the WH-380-E form when seeking leave under FMLA for a serious health condition.
How to fill out wh 380 e form?
To fill out the WH-380-E form, the employee must provide personal information, health care provider information, and details about the serious health condition.
What is the purpose of wh 380 e form?
The purpose of the WH-380-E form is to certify that the employee or their family member has a serious health condition that requires medical leave under FMLA.
What information must be reported on wh 380 e form?
The WH-380-E form must include information about the employee's health condition, treatment plan, and the healthcare provider's certification.
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