Fillable DoL WH-380-E


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Understanding the DoL Form WH-380-E 

When dealing with leave for medical reasons under the Family and Medical Leave Act (FMLA), you are likely to encounter the DoL WH-380-E Form. This form essentially provides a way for your healthcare provider to certify that you require a medical leave of absence from your job.

DoL WH-380-E Form Screenshot

Using of the DoL WH 380 E

The form is usually provided by your employer when you request FMLA leave. It's filled by your healthcare provider to substantiate that you have a serious health condition, thus qualifying you for an FMLA leave. Your employer evaluates this form to decide whether to approve or deny your leave request.

Filling Out Form WH 380 E PDF

If you're wondering about completing and submitting this DoL form, the steps outlined below will guide you through the process:

  1. Start by filling in the 'Employee' section. Input your name, referring to your first, middle, and last names as indicated in the brackets.
  2. Provide your employer's name in the next section.
  3. Indicate the date the certification was requested. Remember to follow the 'MM/DD/YYYY' format.
  4. Identify the date the medical certification must be returned by, once again using the 'MM/DD/YYYY' format.
  5. State your job title next.
  6. In the next part, you'll be asked whether your job description is attached or not. Tick the corresponding box to answer this question.
  7. Proceed to your regular work schedule next, which you must accurately detail.
  8. Provide a statement of your essential job functions.
  9. Once you're done with the employer section, you'll need to fill in the 'Health Care Provider' section next.
  10. The first part will ask for your name. Ensure this matches what's on your medical records.
  11. Fill in the name of your healthcare provider. Ensure it's printed clearly.
  12. State the healthcare provider's business address next.
  13. Indicate the type of practice or medical specialty of your healthcare provider.
  14. Provide the healthcare provider's contact information, including their telephone number, fax, and email.
  15. Date when the condition you're seeking leave for started or will start. The date should be in 'MM/DD/YYYY' format.
  16. You'll be asked to estimate the condition's duration. Provide this information.
  17. There are different boxes asking for the type of medical condition you have. Choose the appropriate box(es) that adequately define your condition.
  18. If you had planned medical treatments, indicate the dates. Similarly, if you were referred to another healthcare provider, provide these details.
  19. If you are required to work a reduced schedule due to your condition, detail this.
  20. Next, if you were incapacitated for a continuous period, include any time for treatment(s) and/or recovery, provide this information.
  21. Lastly, ensure your healthcare provider affixes their signature and the date (in 'MM/DD/YYYY' format) to validate the form.

Remember that providing accurate and honest information is crucial, as any false information may lead to penalties and even your leave being declined. Also, ensure you file in good time to provide your employer with ample time to process your leave request.

Important points to remember

The DoL form WH 380 E allows employers to gather accurate data regarding your medical condition and determine the validity of your leave request. Failure to complete this form appropriately may result in your FMLA leave being denied. As such, it's crucial to ensure that all information is accurate and all sections are fully completed.

If you have any doubts, you should schedule a meeting with your healthcare provider to thoroughly and accurately complete the second section of the form. Consulting a legal professional can also be an effective way to ensure that the form is correctly filled out. The incorrect filling of the form may lead to its rejection, causing unnecessary delays or denial of the medical leave you need.

Fillable online DoL WH-380-E
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