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Provider s name and business address Type of practice / Medical specialty Telephone Fax Page 1 CONTINUED ON NEXT PAGE Form WH-380-E Revised January 2009 PART A MEDICAL FACTS 1. Certification of Health Care Provider for Employee s Serious Health Condition Family and Medical Leave Act U*S* Department of Labor Wage and Hour Division OMB Control Number 1235-0003 Expires 2/28/2015 SECTION I For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER The Family and Medical Leave Act FMLA provides...
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Who needs a Form WH-380-E?

Certification of Health Care Provider for Employee’s Serious Health Condition, Form WH-380-E, should be completed in case when an employer requires an employee seeking Family and Medical Leave Act protections because of a need for a leave due to a serious health condition to provide a medical certification issued by the employee’s health care provider.

This form should be completed by both, the employer and the employee. Also, section 3, the main part of this form should be completed by the employee’s health care provider.

What is Form WH-380-E for?

The employee’s health care provider should provide all applicable facts answering all parts of the form. Based on information provided, an employer can get an idea about the illness of the employee and the time it takes for treatment. Also, this form is used to determine whether the employee actually is subject for FMLA protection.

Is Form WH-380-E accompanied by other forms?

Additional documents are not required in order to complete WH-380-E.

When is Form WH-380-E due?

This form may be requested as needed. Its filling is not regulated by a specific deadline.

How do I fill out Form WH-380-E?

Each of the three parts of this form has its own instructions to be read before filling out.

The following information should be provided in order to complete the form:

  • Employer’s personal information;
  • Employee’s personal information and job title;
  • Provider’s personal and business information;
  • Medical facts Amount of leave needed;
  • Any additional information.

After completion, the signature of the provider should be put.

Where do I send Form WH-380-E?

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. Do not send the completed form to the Department of Labor; Return it to the patient.

Welcome to module 2 in this module will review the forms provided by the Department of Labor for Family Medical Leave situations the website address for the Department of Labor is located in the left-hand corner of the screen at the top WWF OLD of this form entitled certification of health care provider for family members serious health condition is the form that a supervisor would give to his or her employee when that employee needs to take leave to care for a family member this form is also referred to as WH 380 f the first section of the form as you can see is to be completed by the employer and as you can see it's very brief it asks for the employer's name and contact information and that's all there is information in the paragraph above that's important to note it indicates here that the employer is responsible to keep all the records related to the Family Medical Leave and that those records should be kept separate from the personnel file because they contain confidential medical information the next section 2 is for the employee to complete and as you'll see the employee must give his or her name the name of the family member that he or she is going to be caring for the relationship to that family member etc as you'll see there's a sentence right here that indicates your employer must give you 15 calendar days to return this form to your employer if for some reason you don't receive the form back within the 15 calendar days please contact human resources, and we'll reach out to the employee and assist you to get the form back in a timely manner the employee signs and dates the form to verify the information about his or her family member section 3 is for the health care provider to complete and as you'll see it's very thorough it asks for the health care providers name and contact information all the medical facts related to the family member needing a leave such as the patient's condition what type of treatment is needed etc, and it even has a space here for further medical facts if needed Part B of the form indicates the amount of care that's needed, so the doctor indicates exactly what period of time is expected that the employee will need to care for the family member what is the expected period of incapacity will the need lead to be a continuously or intermittent the doctor indicates all of that information so that the supervisor can plan appropriately for the employees leave, and again it has information at the bottom space so that the doctor can indicate any further details that are needed and then of course the doctor signs and dates the form employees who are caring for ill family members are sometimes entitled to receive sick leave so please contact human resources and will guide you and indicate whether that employee is entitled to receive his or her own sick leave while caring for a family member thank you for listening we hope this has been helpful
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