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Official form guide
Form WH-380-E: Certification of Health Care Provider for Employee's Serious Health Condition (FMLA)
Certifies that an employee has a serious health condition requiring leave under the Family and Medical Leave Act (FMLA). Must be completed by a licensed healthcare provider.
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DOL Form WH-380-E - Certification of Health Care Provider for Employee's Serious Health Condition (FMLA)
Certifies that an employee has a serious health condition requiring leave under the Family and Medical Leave Act (FMLA). Must be completed by a licensed healthcare provider.
Risk Radar
Scan points- 1Not returning the form within 15 calendar days — employer may deny FMLA leave.
- 2Healthcare provider not completing all required fields — incomplete certifications will be returned.
- 3Not providing the form to the right healthcare provider — only licensed providers (MD, DO, NP, PA, etc.) can certify.
- 4Employer requesting re-certification too soon — employers can only request re-certification every 30 days in connection with an absence.
Plain English
This form is filled out by your doctor to certify that your medical condition qualifies you for FMLA leave from work.
Submission Date
- Filing date: Submit within 15 calendar days of your employer's request. Your employer must give you at least 15 days notice to submit.
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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Field map
Compact field-by-field guide
Employee Info
2 items
Your full legal name.
Your employer's name.
Medical Provider
4 items
Healthcare provider's full name.
Healthcare provider type (MD, DO, NP, PA, etc.).
Business address of the healthcare provider.
Healthcare provider's phone number.
Condition
2 items
When the serious health condition began.
How long the condition is expected to last.
Leave
2 items
If continuous leave, estimated duration needed.
If intermittent, how many days/week and hours/day of leave needed.
Signature
2 items
Healthcare provider's signature.
Date provider signed the form.
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