Employers can ask for this Department of Labor certification when an employee requests FMLA leave for their own serious health condition. The treating clinician records when the condition started, how long it should last, which serious health condition category applies and how much continuous, reduced-schedule or intermittent leave is needed. The patient returns the completed form to the employer, which uses it to grant or deny FMLA protection.
The employee's health care provider completes Section II: contact details, Parts A to C and the signature. Section I, with the employer name, return date and the employee's essential job functions, may be filled in by either the employer or the employee.
Filled in by the employer or the employee before the form reaches you: employee and employer names, the date certification was requested, the return date (at least 15 calendar days later), job title, regular work schedule and a statement of essential job functions or an attached job description. Part C relies on this statement; if it is blank, the form tells you to answer from the employee's own description of the job.
Print your name, business address, type of practice or specialty, telephone, fax and email. The instructions explain that a serious health condition involves inpatient care or continuing treatment by a health care provider, that adding symptoms or a diagnosis is optional, and that some state or local laws may not allow disclosure of a diagnosis or course of treatment. Answers are your best estimate from knowledge, experience and examination.
Questions 1 to 4. Give the approximate start date and your best estimate of how long the condition lasted or will last, then check each category that applies: inpatient care, incapacity plus treatment (more than three consecutive full calendar days, with visit dates), pregnancy with the expected delivery date, chronic condition, permanent or long-term condition, or multiple treatments. If none applies, skip to page 4 and sign. Question 4 allows brief extra facts, such as dialysis.
Questions 5 to 9 cover scheduled treatment visits with dates, referrals to other providers with a start date and duration, a medically necessary reduced schedule, a continuous period of incapacity with begin and end dates, and intermittent absences for flare-ups. For intermittent leave, estimate how many episodes occur per day, week or month over the next six months and how many hours or days each lasts. Every box checked in Part A needs an amount here.
Question 10 asks whether the employee was, is or will be unable to perform one or more essential job functions, and asks you to identify at least one. Use the employer's statement in Section I, or the employee's own description if none was provided. The form notes that an employee who must be absent for scheduled medical treatment is considered unable to perform essential functions during that absence.
Sign and date at the bottom of page 4, then return the form to the patient. The same page reprints the DOL definitions of a serious health condition (29 C.F.R. 825.113 to 825.115), including the visit rules for incapacity plus treatment: two in-person visits within 30 days with the first within seven days, or one visit within seven days that starts a regimen of continuing treatment.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act
Certificado del proveedor de atención médica para la condición de salud grave de un empleado conforme a la Ley de Ausencia Familiar y Médica
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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DOL counts doctors of medicine or osteopathy authorized to practice in the state, plus podiatrists, dentists, clinical psychologists, optometrists and chiropractors (with limitations), and nurse practitioners, nurse-midwives, clinical social workers and physician assistants acting within their scope of practice. Christian Science practitioners and any provider the employer or its group health plan accepts for substantiating benefit claims also qualify.
No. The form says the provider may, but is not required to, add other medical facts such as symptoms, diagnosis or a treatment regimen, and it notes that some state or local laws limit disclosure of a diagnosis. Do not include genetic test results, genetic services or the medical history of the employee's family members, which the form excludes.
Yes. The Wage and Hour Division posts a Spanish version of WH-380-E next to the English fillable PDF on its forms page. Employers must accept a complete and sufficient certification regardless of format, so an employer's own form asking for the same information is equally valid.
Only to authenticate or clarify a complete and sufficient certification, and only through a human resources professional, leave administrator, management official or another health care provider. The employee's direct supervisor may never contact the provider, and the employer cannot request additional information beyond what the certification requires.