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FMLA Medical Certification Form (Employee): Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act
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Form WH-380-E in short
Form WH-380-E is the Department of Labor's optional form for a health care provider to certify an employee's own serious health condition when the employee asks for leave under the Family and Medical Leave Act (FMLA). The employer or employee fills in Section I, and the employee's health care provider completes Section II. The completed form goes back to the employee, who gives it to the employer.
| Issued by | U.S. Department of Labor, Wage and Hour Division (WHD) |
|---|---|
| Current version | Revised June 2020 (checked 2026-10-25) |
| Who fills it in | An employee who needs FMLA leave for their own serious health condition, when the employer asks for medical certification. The employee's health care provider completes and signs the medical part. |
| Who receives it | The employer. The form says not to send it to the Department of Labor and to return it to the patient, who then gives it to the employer. |
| Where to send it | Give the completed form to your employer. Do not send it to the U.S. Department of Labor or the Wage and Hour Division. |
| Deadline | The employer must give the employee at least 15 calendar days to provide the certification, unless that is not feasible despite the employee's diligent, good faith efforts. The return date is written at item 3 of Section I. |
| Official links | Official page · Official PDF |
How to fill out Form WH-380-E, line by line
| Section I, items 1 to 3 | Employee name, employer name and return date Either the employee or the employer can fill in Section I. Enter the date the certification was requested and the date it must be returned, which must allow at least 15 calendar days. |
| Section I, item 4 | Job title, work schedule and essential job functions Enter the job title, regular work schedule and a statement of the essential job functions. Say whether a job description is attached. The provider may use this to answer Part C. |
| Section II | Health care provider details The provider prints their name, business address, type of practice or medical specialty, and phone, fax and email. |
| Part A, items 1 to 3 | Medical information The provider gives the approximate start date and likely duration of the condition and checks the boxes that apply: inpatient care, incapacity plus treatment, pregnancy, chronic condition, permanent or long term condition, or multiple treatments. If none apply, the provider goes straight to the signature. |
| Part A, item 4 | Other medical facts Optional. The provider may briefly describe other relevant medical facts, such as use of a nebulizer or dialysis. |
| Part B, items 5 to 9 | Amount of leave needed The provider estimates planned treatment dates, referrals, any reduced schedule, any continuous period of incapacity, and for intermittent leave how often flare-ups occur and how long each lasts over the next 6 months. |
| Part C, item 10 | Essential job functions The provider says whether the employee cannot perform one or more essential job functions and names at least one. |
| Page 4 | Health care provider signature and date The health care provider signs and dates the form. |
Common mistakes to avoid
- Sending the completed form to the Department of Labor. It goes back to the employee, who gives it to the employer.
- Setting a return date less than 15 calendar days after the request in Section I.
- Using this form for a family member's condition. Leave to care for a family member uses Form WH-380-F.
- Answers such as lifetime, unknown or indeterminate in Part B. The form says these may not be enough to decide FMLA coverage.
- Leaving Part B blank after checking a box in Part A. For every box checked, the amount of leave needed must be given in Part B.
- Including genetic test results or family medical history. The form tells the provider not to give this information.
- Not naming at least one essential job function the employee cannot perform in Part C.
- Forgetting the provider's signature and date on page 4.
Questions about Form WH-380-E
Do I have to use Form WH-380-E?
No. The Department of Labor says its FMLA forms are optional. An employer may use its own form with the same basic information, and an employee can provide the required information in any format, such as on the health care provider's letterhead.
How long do I have to return the FMLA certification?
The employer must allow at least 15 calendar days. The Department of Labor says employees must be allowed more time in some cases, such as when the health care provider cannot complete it on time.
Where do I send the completed form?
To your employer. The form and the Department of Labor say not to send completed certifications to the Department of Labor or the Wage and Hour Division.
Does my doctor have to give a diagnosis?
No. The form says the provider may, but is not required to, give other medical facts such as symptoms or a diagnosis. It also notes that some state or local laws may not allow disclosure of a diagnosis.
The OMB expiration date has passed. Is the form still valid?
The Department of Labor says yes. The expiration date relates to the OMB information collection approval and not to the content of the form. The current PDF shows an OMB expiry of 8/31/2029.
What if the certification is incomplete?
The employer must tell you in writing what is missing, usually with Form WH-382, and give you at least 7 calendar days to fix it. If you do not provide complete and sufficient certification, the leave request may be denied.
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Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the U.S. Department of Labor, Wage and Hour Division or any government agency. This page is general information, not legal or tax advice.