FMLA Form Wh-380-f Revised May 2015

Form WH-380-F Revised May 2015 PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or

Questions about this form? Contact Leave Administration at (919) 515-2151 Revised: May 2015. Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act) SECTION I: For Completion by the EMPLOYER. Employee’s essential job functions: Employee’s job title: Regular work schedule: INSTRUCTIONS to the EMPLOYER:

Form WH-380-F Revised May 2015 PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or

this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or

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

Page 1 Form WH-380-F Revised May 2015 OMB Control Number: 1235-0003 Expires 05/31/2018 Certification of Health Care Provider for U.S. Department of Labor. Family Member’s Serious Health Condition (Family and Medical Leave Act) Wage and Hour Division . Employer contact Information: Lenora Salts Phone Number: 402-280-4753 FAX Number: 402-28. 0 …

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:

Revised: May 2015. Certification of Health Care Provider for Family Member’s Serious Health Condition … While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical …