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CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEES SERIOUS HEALTH CONDITION (FAMILY AND MEDICAL LEAVE ACT) Adapted from Form WH380E Revised June 2020 Expires 6/30/2023SECTION IEMPLOYER Either the

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How to fill out adapted from form wh-380-e

01

Start by obtaining the adapted form WH-380-E from your employer or the Department of Labor's website.

02

Fill out your personal information at the top of the form, including your name, address, and contact information.

03

Indicate the reason for your request under the 'Reason for Leave' section, ensuring it aligns with the Family and Medical Leave Act (FMLA) criteria.

04

Provide the dates for which you are requesting leave, including the start date and the expected return date.

05

If applicable, include information about any alternative work arrangements or accommodations.

06

Sign and date the form at the bottom to confirm that the information provided is accurate.

Who needs adapted from form wh-380-e?

01

Employees who are seeking leave for qualifying medical conditions or for the care of a family member under the Family and Medical Leave Act (FMLA) may need to complete the adapted form WH-380-E.

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What is adapted from form wh-380-e?

Adapted from form WH-380-E is a modified version of the original form designed to collect specific information related to employee leave under the Family and Medical Leave Act (FMLA).

Who is required to file adapted from form wh-380-e?

Employees who are requesting leave under the Family and Medical Leave Act (FMLA) due to their own serious health condition or that of a family member are required to file this adapted form.

How to fill out adapted from form wh-380-e?

To fill out the adapted form, individuals should provide their personal information, details about the leave request, and any relevant medical information as required by the guidelines of the form.

What is the purpose of adapted from form wh-380-e?

The purpose of the adapted form WH-380-E is to formally request leave under FMLA by providing necessary documentation of a serious health condition, thereby ensuring compliance with federal regulations.

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

The information that must be reported includes the employee's name, contact information, type of leave requested, dates of absence, and details pertaining to the medical condition.

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