FMLA Forms Wh-380-f

Certification Forms *WH–380-E Employee’s Own Serious Illness *WH-380-F Illness of Employee’s Family Member *WH-384 Certification of Qualifying Exigency for Military Family Leave *WH-385 Certification for Serious Injury or Illness of Covered Service . Member for Military Family Leave *Form numbers are located on the bottom right hand side of the forms listed …

For FMLA to apply, care of the patient must be medically necessary. Briefly describe the type of care needed by the patient (e.g., assistance with basic medical, hygienic, nutritional, safety, transportation needs, physical care, or psychological com fort). Page 2 of 4 Form WH-380-F, Revised June 2020

Page 1 Form WH–380-E Revised May 2015 Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition Wage and Hour Division (Family and Medical Leave Act) DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT . OMB Control Number: 1235-0003 Expires: 8/31/2021. …

1/2011. FMLA Medical Certification for Family Member. WH-380-F. 5/2015. FMLA Certification of Qualifying Exigency for Military Family Leave. WH-384. 2/2013. FMLA Certification for Serious Injury or Illness of a VETERAN for Military Caregiver Leave. WH-385-V.

a covered family member with a “serious health condition” under 29 C.F.R. § 825.113 of the FMLA. If such leave is requested, you may be required to complete DOL FORM WH-380-F or an employer-provided form seeking the same information. PART C: AMOUNT OF LEAVE NEEDED For the medical condition checked in Part B, complete all that apply. Some questions seek a …

sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305. Your name: _____ First Middle Last . Name of family member for whom you will provide care:_____ First Middle Last . Relationship of family member to you: _____ If family …

The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider. 29 U.S.C. §§ 2613, 2614(c)(3); 29 C.F.R. § 825.305.

WH–380-E: FMLA Certification of Health Care Provider for Employee’s Serious Health Condition. WH–380-E Form & Instruction; WH-380-F: FMLA Certification of Health Care Provider for Family Member’s Serious Health Condition. WH-380-F Form & Instruction; WH-381: FMLA Notice of Eligibility and Rights & Responsibilities. WH-381 Form & Instruction …