Employers can request this Department of Labor certification when an employee takes FMLA leave to care for a spouse, parent or child with a serious health condition. The family member's own clinician confirms the condition, that care is medically necessary, and how much continuous, reduced-schedule or intermittent leave the employee needs. The completed form goes back to the patient or employee, who hands it to the employer.
The family member's health care provider completes Section III, Parts A and B, and signs. Section I is completed by the employer or employee, and Section II, describing the care the employee will provide and the time needed, is completed and signed by the employee.
The employer or employee enters the employee's name, the employer's name, the date certification was requested and the date it must be returned, which must allow at least 15 calendar days. Unlike WH-380-E, Section I has no job title or essential-functions statement. The employer may not request this certification for leave to bond with a healthy newborn or a child placed for adoption or foster care.
Completed and signed by the employee before the form reaches you: the family member's name, the relationship (spouse, parent, child under 18, or adult child incapable of self-care because of a disability), the care the employee will give, a best estimate of leave in hours per day and days per week, and any reduced schedule. Reading it first helps your Part B estimates line up with the care described.
Print your name, business address, type of practice or specialty, telephone, fax and email. The instructions explain that a family member of your patient has requested leave to care for them, that adding symptoms or a diagnosis is optional, and that some state or local laws restrict disclosure. Answers should be your best estimate based on your medical knowledge, experience and examination of the patient.
Questions 1 to 6: the patient's name, approximate start date, expected duration, and a description of the care the patient needs, since care must be medically necessary for FMLA to apply. Then check each category that fits (inpatient care, incapacity plus treatment, pregnancy, chronic condition, permanent or long-term condition, multiple treatments) and give a leave amount in Part B for each. Question 6 allows other relevant facts, such as nebulizer use.
Questions 7 to 10 ask for scheduled treatment visits, referrals with a start date and duration, any continuous period of incapacity with begin and end dates, and whether the employee must be absent intermittently to care for the patient during flare-ups. For intermittent care, estimate how often episodes occur per day, week or month over the next six months and how many hours or days each lasts.
Sign and date at the end of Part B on page 4, then return the form to the patient or the employee. The same page reprints the DOL definitions of a serious health condition (29 C.F.R. 825.113 to 825.115), which help confirm which Part A category applies, including the visit timing rules for incapacity plus treatment and the twice-a-year visit standard for chronic conditions.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Family Member'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 familiar 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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The employee does. Section II names the family member and the relationship, describes the care the employee will provide, and gives a best estimate of the leave needed in hours per day and days per week, plus any reduced schedule. The employee signs it before giving the form to the family member or the family member's provider.
No. The provider may add symptoms, a diagnosis or a treatment regimen but is not required to, and the form notes that some state or local laws limit disclosure of that information. What the certification needs is the start date, expected duration, the care required, the serious health condition category and the amount of leave.
Yes. The Wage and Hour Division posts a Spanish version of WH-380-F alongside the English fillable PDF on its forms page. Employers may also use their own certification forms, but they cannot request more information than the FMLA regulations at 29 C.F.R. 825.306 to 825.308 allow.
Generally no more than every 30 days and only in connection with an absence, or after the certified minimum duration when that is longer than 30 days, though an employer may ask every six months regardless. If the need for leave carries into a new FMLA leave year, the employer may require a new certification.