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Form WH-380-E, Certification of Health Care Provider for Employee's Serious Health Condition
What is WH-380-E?
WH-380-E is the Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act from the U.S. Department of Labor, Wage and Hour Division.
DOL directs use of this form when a leave request is due to the medical condition of the employee.
Use of WH-380-E is optional.
How Form WH-380-E is used
Completed certifications should be given to the employee to provide to the employer, and should not be sent to DOL’s Wage and Hour Division.
Employers must accept a complete and sufficient certification regardless of format, including a fax or copy.
Either the employee or the employer may complete Section I; Section II instructs the health care provider to provide contact information, complete all relevant parts of that section, and sign the form.
DOL’s FMLA forms page links WH-380-E.
The blank on this page
The blank is marked “Form WH-380-E, Revised June 2020”.
You can fill in this blank in the PDFLiner editor.
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Fillable online Form WH-380-E