FMLA Form WH-380-E Certification of Health Care Provider for Employee’s Serious Health Condition

The Family and Medical Leave Act of 1993 allows employees to go on job-protected leaves. Depending on the situation you’re in, you can fill out the FMLA form for your condition and go on unpaid leave for a specific amount of days.

One of the most common FMLA forms is the WH-380-E (Certification of Health Care Provider for Employee’s Serious Health Condition) which allows the employee to take leave for his or her medical condition. Just like all the other FMLA forms, the WH-380-E has three sections one of which will be completed by the employee. The rest will be completed by the employer and the health care provider.

You as an employee who needs leave for medical will fill out the form and detail your medical condition. The information found on FMLA Form WH-380-E includes

  • How many days of leave you need and whether it will be sporadic or continuous.
  • Whether the condition requires a follow-up treatment or not.
  • Your symptoms, treatment, and diagnosis.
  • How long the medical condition might last.
  • Which of the job responsibilities your condition prevents you from performing.
  • When the condition began
  • Whether your medical condition requires an overnight stay in a medical facility. If so, when.

After you and your employer complete the WH-380-E, you can then take it to your healthcare provider. There is no reason for your doctor not to complete the FMLA Form. Unfortunately, if you don’t hear from your doctor or simply your doctor doesn’t complete the form, there isn’t anything you can do, legally.

If a situation like this occurs, we suggest taking it to another medical professional that can explain your diagnosis and how it will affect your work. Need a blank Form WH-380-E? Visit our front page to see the full list of forms download in PDF.

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