FMLA Form Wh-380-e

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 above. …

For FMLA purposes, a “serious health condition” means an illness, injury, impairment, or physical or mental condition that … Page 1 of 4 Form WH-380-E, Revised June 2020 . U.S. Department of Labor Wage and Hour Division Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act. DO NOT SEND COMPLETED FORM TO THE …

WH-347: DBRA Certified Payroll Form. Revised WH-347 Form & Instruction Applicable to Contracts Entered into Pursuant to Invitations for Bids Issued or Negotiations Concluded On or After January 18, 2009. WH-380-E: FMLA Certification of Health Care Provider for Employee’s Serious Health Condition. WH-380-E Form & Instruction; WH–380-F: FMLA …

Page CONTINUED1 ON NEXT PAGE Form WH -380 E Revised May 2015 _____ Certification of Health Care Provider for U.S. Department of Labor . Employee’s Serious Health Condition (Family and Medical Leave Act) Wage and Hour Division . OMB Control Number: 1235-0003 . Expires: 8/31/2021 SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER: …

Page 1 Form WH-380-E Revised May 2015 Certification of Health Care Provider for U.S. Department of Labor … Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious …

Form WH 380-E, Certification of Health Care Provider for Employee’s Serious Health Condition, is a form used by employers and sent to the US Department of Labor, Wages and Hour Division. This form verifies that an employee has a serious medical condition. It documents certain information about the employer, the employee, and the healthcare provider treating the employee. The …

Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 …

Page 1 of 4 Form WH-380-E, Revised June 2020 . Employee Name: Health Care Provider’s name: (Print) Health Care Provider’s business address: Type of practice / Medical specialty: Telephone: Fax: E-mail: PART A: Medical Information . Limit your response to the medical condition(s) for which the employee is seeking FMLA leave. Your answers should be your best estimate based …