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Certification of Health Care Provider for Employees Serious Health Condition under the Family and Medical Leave Act. S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED FORM TO THE
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How to fill out wh-380-e certification of health

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How to fill out wh-380-e certification of health

01
To fill out the WH-380-E Certification of Health form, follow these steps:
02
Begin by entering the employee's name and job position at the top of the form.
03
Check the appropriate box indicating whether the employee is requesting leave for their own serious health condition or the serious health condition of a family member.
04
Provide the start and end dates of the requested leave in the designated fields.
05
Indicate the expected duration of the leave by selecting one of the provided options.
06
If applicable, specify intermittent or reduced schedule leave details, including the estimated frequency and duration of the leave.
07
Document any known medical facts related to the serious health condition, including diagnosis, treatment, and healthcare providers involved.
08
If the employee is seeking leave to care for a family member, provide relevant information about the family member's condition and treatment.
09
Attach any supporting medical documentation, such as doctor's notes or medical test results.
10
Sign and date the form to certify the accuracy of the information provided.
11
Ensure that the healthcare provider signs and dates the form as well.
12
Keep a copy of the completed form for your records and submit it to the appropriate department for processing.

Who needs wh-380-e certification of health?

01
Employees who are covered by the Family and Medical Leave Act (FMLA) need to fill out the WH-380-E Certification of Health form.
02
This includes eligible employees who require leave for their own serious health condition or to care for a family member with a serious health condition.
03
The certification helps employers verify the need for leave and ensures compliance with FMLA regulations.
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The WH-380-E certification of health is a form used by the Department of Labor to provide information about an employee's or family member's serious health condition for leave under the Family and Medical Leave Act (FMLA).
Employees or their family members are required to file the WH-380-E certification of health when requesting leave under the FMLA based on a serious health condition.
The WH-380-E certification of health must be completed by a healthcare provider and returned to the employer to support the employee's request for leave under the FMLA.
The purpose of the WH-380-E certification of health form is to provide medical documentation of a serious health condition that requires leave under the FMLA.
The WH-380-E certification of health form must include details about the nature of the serious health condition, the treatment plan, and the expected duration of the leave needed.
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