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This document is a certification form required under the Family and Medical Leave Act (FMLA) for employees requesting leave to care for a covered servicemember with serious injury or illness.

How to fill out certification for serious injury

How to fill out Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)

1. Obtain the Certification for Serious Injury or Illness of Covered Servicemember form from your employer or online.
2. Fill in the employee's name and information at the top of the form.
3. Provide information on the servicemember’s condition explicitly, including the nature of the serious injury or illness.
4. Include details regarding the date that the servicemember was injured or diagnosed.
5. Specify the expected duration of the serious injury or illness.
6. Have the healthcare provider complete the sections regarding the medically necessary care required for the servicemember.
7. Sign and date the form to certify its accuracy and completeness.
8. Submit the completed certification form to your employer within the required timeframe.

Who needs Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)?

1. Family members of servicemembers who have incurred a serious injury or illness during active duty.
2. Employees who wish to take Military Family Leave under the Family and Medical Leave Act (FMLA) to care for a covered servicemember.

People Also Ask about

What certification is needed for FMLA?

Certification forms. The FMLA does not require the use of any specific certification form. The Department has developed optional forms that can be used for leave for an employee's own serious health condition (WH-380-E) or to care for a family member's serious health condition (WH-380-F).

What certification do you need for FMLA?

Certification forms. The FMLA does not require the use of any specific certification form. The Department has developed optional forms that can be used for leave for an employee's own serious health condition (WH-380-E) or to care for a family member's serious health condition (WH-380-F).

Is your request for leave due to a serious injury or illness of a military servicemember?

The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave to care for a covered servicemember with a serious illness or injury. The FMLA allows an employer to require an employee seeking FMLA leave for this purpose to submit a medical certification.

Can any doctor complete FMLA paperwork?

The FMLA regulations on the Department of Labor website state that certification can be provided by a licensed healthcare provider — which may include a doctor of medicine or osteopathy, nurse practitioner, or physician assistant.

How do you qualify for FMLA in the military?

To be eligible to take FMLA leave for any qualifying reason, an employee of a covered employer must have worked for the employer for a total of 12 months, have worked at least 1,250 hours over the previous 12 months, and work at a location where at least 50 employees are employed by the employer within 75 miles.

What does an employer need to do for FMLA?

If you approve an employee for FMLA leave, you must: Protect your employee's job while on FMLA leave. Maintain their access to group health benefits. Not retaliate or discriminate against an employee for taking FMLA leave.

Can an employer approve FMLA without certification?

If an employee does not provide either a complete and sufficient certification or an authorization allowing the health care provider to provide a complete and sufficient certification to the employer, the employee's request for FMLA leave may be denied.

Is a serious injury or illness covered by FMLA?

TYPES OF SERIOUS HEALTH CONDITIONS. The FMLA defines a serious health condition as an illness, injury, impairment, or physical or mental condition that involves either inpatient care or continuing treatment by a health care provider. Both physical and mental health conditions qualify for FMLA leave.

For pdfFiller’s FAQs

What is Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)?

It is a form used by eligible employees to certify the serious injury or illness of a covered servicemember, allowing them to take leave under the Family and Medical Leave Act (FMLA) to care for that individual.

Who is required to file Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)?

The employee who is taking FMLA leave to care for a covered servicemember with a serious injury or illness is required to file this certification with their employer.

How to fill out Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)?

To fill out the certification, the employee must provide details about the covered servicemember, the nature of the injury or illness, and the need for care, usually with input from a healthcare provider.

What is the purpose of Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)?

The purpose of the certification is to verify the serious injury or illness of a servicemember, ensuring that the employee qualifies for FMLA leave to provide necessary care.

What information must be reported on Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (FMLA)?

The certification must include the servicemember's name, service branch, the type of serious injury or illness, the dates of treatment, and the expected duration of the need for care, among other required details.