Fillable Form WH 380-E

What is Form WH 380-E?

Form WH-380-E is a certification of health care form, used for the Family and Medical Leave Act (FMLA) in the United States. Of the FMLA forms, this one is specifically designed to provide medical certification for an employee's serious health condition, serious injury, or other qualifying exigency, which is required by their employer as part of the FMLA process.

This form allows an employee to have their healthcare provider (such as a doctor or military caregiver) certify the serious health condition that necessitates their need for leave under the FMLA.

Employers may request this form from employees who are requesting FMLA leave for their own serious health condition as part of the process to approve and administer FMLA leave, as well as general practice, as it is often necessary to provide sufficient medical certification in order to confirm that a given medical condition is real and has serious effects on the employee, the employee's spouse, a family member, and so on. It helps to ensure that the leave request is legitimate and covered under the FMLA regulations.

Note that leave may still be unpaid leave, and things such as wage hour division will naturally be affected even if this form is filed properly. Make sure to check with your employer to see how medical leave is handled within the company as well.

How do I fill out Form WH 380-E?

A fillable copy of the WH 380-E form can be found here. It is highly important to have a healthcare professional (a doctor, military caregiver, or any other provider for employee's serious health concerns) present as this form is filled out, in order to ensure that their medical advice is properly and accurately recorded, and basic information about the employee's condition is included.

Military family members may be able to consult their military family member's caregiver, depending on existing policies.

Section I - Employer

Employee Name

Enter the employee’s full legal name.

Employer Name

Enter the name of the employer, then enter the date that certification was requested.

Medical Certification Return Date

Enter the date that the medical certification should be returned by.

Employee’s Job Details

Enter the following details about the employee’s job.

• Job title
  • Mark the corresponding box to indicate if you are attaching a job description to this form.
• Regular work schedule
• Essential job functions

Section II - Health Care Provider

Employee Name

At the beginning of this page and all pages following this one, enter the employee’s full legal name in the space provided.

Health Care Provider Details

Enter the following details about the health care provider.

• Name
• Business address
• Type of practice/Medical specialty
• Telephone number
• Fax number
• Email address

Part A - Medical Information

Item 1 - Date Condition Started

Enter the approximate date that the condition started or will start.

Item 2 - Estimated Duration

Enter the estimated duration of the condition.

Item 3 - Questions

Check the boxes for the questions below as applicable, then answer the questions you check the boxes for.

• Inpatient Care
  • Mark the box corresponding to if the patient has been or is expected to be admitted for overnight care, then enter the date that they were or will be admitted.
• Incapacity plus Treatment
  • Mark the box corresponding to if the patient has been or is expected to be incapacitated for more than three consecutive, full calendar days. Then enter the date range during which they will be (or were) incapacitated.
  • Mark the box corresponding to whether the patient was seen or will be seen on a particular date. Enter that date.
  • Mark the box corresponding to whether or not the condition has resulted in a course of continuing treatment under the supervision of the health care provider.
• Pregnancy
  • Enter the expected date of delivery.
• Chronic Conditions
• Permanent or Long-Term Conditions
• Conditions Requiring Multiple Treatments
• None of the Above

Item 4 - Other Information

Enter any other relevant or important medical information related to the condition(s) for which the employee is seeking to obtain FMLA leave.

Part B - Amount of Leave Needed

Complete all of the below items that apply, based on the items in Part A.

Item 5 - Planned Medical Treatment

Mark the box that corresponds to whether the patient has had or will have planned medical treatment(s), then enter the dates on which planned treatment was or will be conducted.

Item 6 - Referral

Mark the box that corresponds to whether the patient was or will be referred to another medical professional. Then provide the following information:

• Nature of treatments to be done
• Best estimate of beginning and end date of treatments
• Best estimate of the duration of the treatments, including recovery periods.

Item 7 - Reduced Schedule

Provide the best estimate of the reduced schedule the employee is able to work. Enter the following information:

• The beginning and end date of when the employee must work a reduced schedule
• Hours per day working

Item 8 - Continuous Incapacitation

Mark the box that corresponds to whether the patient will be or was incapacitated for an extended period of time. Then enter the beginning and end dates for the patient’s period of incapacity.

Item 9 - Intermittent Absence

Mark the box that corresponds to whether the patient was, is, or will be intermittently absent for medical reasons. Then enter the following information:

• Number of times per day, week, or month episodes of incapacity are expected to occur over the next 6 months
• Duration of each episode in hours or days

Part C - Essential Job Functions

Item 10 - Inability to Perform

Mark the box that corresponds to whether the patient was, is, or will not be able to perform one or more of the essential functions of their position. Then enter the essential function they will not be able to perform.

Signature

Have the health care provider filling out this form sign the form in the space provided, then enter the date that the form was signed.

Frequently Asked Questions (FAQs)

Can an employee submit Form WH-380-E after taking FMLA leave?

It's best for employees to submit Form WH-380-E before or at the beginning of their FMLA leave. However, in some cases, it may be accepted after leave has commenced.

Can an employer recommend a health care provider for an employee?

Yes, employers may recommend a health care provider for employee's benefit and consultation.

What happens if an employee doesn't submit Form WH-380-E?

Failure to submit Form WH-380-E as requested by the employer may result in delays or denial of FMLA leave.

Can an employer request additional medical documentation beyond Form WH-380-E?

Yes, an employer may request additional medical documentation if necessary to support the employee's FMLA leave request.

Can an employer contact the healthcare professional listed on Form WH-380-E?

Yes, employers are allowed to contact the health care provider listed on Form WH-380-E for clarification or verification of the information provided.

Can an employer deny FMLA leave based on the information provided on Form WH-380-E?

Employers can deny FMLA leave if the information provided on Form WH-380-E does not support the employee's eligibility for FMLA leave.

How long is Form WH-380-E valid for?

Form WH-380-E is generally valid for the duration of the FMLA leave or until the medical examiner updates the employee's condition.

Can an employer require a second opinion if they doubt the information on Form WH-380-E?

Yes, employers have the right to request a second opinion from a different healthcare provider if they doubt the validity of the information provided on Form WH-380-E.

Can an employee refuse to submit Form WH-380-E?

Refusal to submit Form WH-380-E as requested by the employer may result in denial of FMLA leave.

Can an employer require an employee to provide updates on their condition after submitting Form WH-380-E?

Yes, employers may request periodic updates on the employee's condition to ensure ongoing eligibility for FMLA leave.

Can an employer retaliate against an employee for submitting Form WH-380-E?

No, retaliation against an employee for exercising their rights under the FMLA, including submitting Form WH-380-E, is prohibited.

Can an employer require an employee to pay for the completion of Form WH-380-E?

No, employers are responsible for any costs associated with completing Form WH-380-E.

Can an employer require an employee to provide a specific healthcare expert to complete Form WH-380-E?

No, employers cannot require employees to use a specific medical expert to complete Form WH-380-E.

Can an employee request accommodations based on the information provided on Form WH-380-E?

Yes, employees may request accommodations based on their serious health condition as certified on Form WH-380-E, if applicable under the Americans with Disabilities Act (ADA).

Can an employer discipline an employee for absences covered by FMLA leave and certified on Form WH-380-E?

No, employers cannot discipline an employee for absences covered by FMLA leave and certified on Form WH-380-E.

Can an employer require an employee to submit Form WH-380-E for mental health conditions?

Yes, Form WH-380-E can be used to certify mental health conditions if they meet the criteria for a serious health condition under the FMLA.