Get the free DOL WH-380-E Form - Certification By Employee's Health Care ... - cinciapwu

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:

How to fill out dol wh-380-e form

How to fill out dol wh-380-e form:

1. Start by entering your personal information at the top of the form, including your name, address, and phone number.
2. Next, provide the name of the injured employee and their job title or position.
3. Indicate the date of the employee's injury or illness in the designated section.
4. Explain how the injury or illness occurred, providing details on the date, time, and place of the incident.
5. If applicable, state whether the employee's injury or illness was caused by a specific event or exposure at work.
6. Describe the nature of the injury or illness, including affected body parts and any medical treatment received.
7. Fill in the medical and healthcare provider information, including the name and address of the healthcare professional who treated the employee.
8. If the employee was hospitalized, provide details on the hospital or medical facility where they were admitted.
9. Indicate the expected duration of the employee's absence from work due to the injury or illness.
10. In the last section of the form, include your contact information as the employer or supervisor, along with the date and your signature.

Who needs dol wh-380-e form:

1. Employers are required to provide Form WH-380-E to employees who have suffered a work-related injury or illness that qualifies under the Family and Medical Leave Act (FMLA).
2. The injured employee also needs to complete certain sections of the form to provide details about their injury, medical treatment, and expected time off work.
3. Both the employer and the employee should keep a copy of the completed form for their records and for any necessary submissions to the Department of Labor.

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What is dol wh-380-e form?

The DOL WH-380-E form is a certification of healthcare provider for an employee's serious health condition under the Family and Medical Leave Act (FMLA).

Who is required to file dol wh-380-e form?

Both the employee and the healthcare provider are required to fill out and file the DOL WH-380-E form.

How to fill out dol wh-380-e form?

The employee must provide their information and the healthcare provider must certify the employee's serious health condition.

What is the purpose of dol wh-380-e form?

The purpose of the DOL WH-380-E form is to certify an employee's serious health condition and determine eligibility for FMLA leave.

What information must be reported on dol wh-380-e form?

The DOL WH-380-E form must include the employee's personal information, the healthcare provider's certification of the serious health condition, and the duration of the condition.