Form WH-380-F, Certification of Health Care Provider for Family Member’s Serious Health Condition

What is WH-380-F?

WH-380-F is the Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act (FMLA), from the U.S. Department of Labor, Wage and Hour Division. DOL lists it on its FMLA forms page for a family member's serious health condition; its sibling form, WH-380-E, is for the employee's own condition. DOL calls these "optional-use forms."

Who completes which section

• Section I, Employer: the form says "Either the employee or the employer may complete Section I."
• Section II, Employee: you complete and sign it before giving the form to your family member or their health care provider. It asks for the family member's name, their relationship to you, and the care you will provide.
• Section III, Health Care Provider: completed by the family member's health care provider.

How it is used

DOL says employers must accept a complete and sufficient certification regardless of the format, including a fax or copy. Do not send completed certification forms to DOL's Wage and Hour Division: return them as your employer instructs.

The blank on this page

The blank is marked "Form WH-380-F, Revised June 2020" and shows "Expires: 8/31/2029". You can fill it in with the PDFLiner editor. See also Form WH-380-E for the employee's own serious health condition.