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FMLA Medical Certification Form (Family Member): Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act
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Form WH-380-F in short
Form WH-380-F is the Department of Labor's optional form for a health care provider to certify a family member's serious health condition when an employee asks for FMLA leave to care for that family member. The employer or employee fills in Section I, the employee fills in and signs Section II, and the family member's health care provider completes Section III. The employee then gives the completed form 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 to care for a spouse, parent, or child with a serious health condition, when the employer asks for medical certification. The family member's health care provider completes the medical part. |
| Who receives it | The employer. The form says not to send it to the Department of Labor. |
| 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-F, 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 II, items 1 and 2 | Family member and relationship The employee names the family member and selects the relationship: spouse, parent, child under 18, or child 18 or older who cannot care for themselves because of a mental or physical disability. In loco parentis relationships count, and no legal or biological relationship is needed. |
| Section II, items 3 to 5 | Care you will provide and leave needed The employee describes the care they will give, such as transportation, physical care or psychological comfort, estimates the leave needed and any reduced schedule, then signs and dates Section II before passing the form to the provider. |
| Section III | 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 6 | Medical information The provider gives the patient's name, when the condition started, how long it will last and the type of care needed, then checks the boxes that apply, such as inpatient care, chronic condition or pregnancy. |
| Part B, items 7 to 10 | Amount of leave needed The provider estimates planned treatment dates, referrals, any continuous period of incapacity, and for intermittent leave how often flare-ups occur and how long each lasts over the next 6 months. |
| Page 4 | Health care provider signature and date The health care provider signs and dates the form. |
Common mistakes to avoid
- Not completing and signing Section II before giving the form to the family member's health care provider.
- Using this form for a family member who does not qualify, such as a sibling or in-law. The form lists spouse, parent and child, including in loco parentis relationships.
- Listing a child aged 18 or older without the box for a child incapable of self-care because of a mental or physical disability.
- Using this form for your own condition. Your own serious health condition uses Form WH-380-E.
- Leaving Part B blank after checking a box in Part A.
- Answers such as lifetime, unknown or indeterminate in Part B, which the form says may not be enough.
- Sending the completed form to the Department of Labor instead of the employer.
Questions about Form WH-380-F
Which family members does WH-380-F cover?
A spouse, a parent, a child under 18, or a child 18 or older who cannot care for themselves because of a mental or physical disability. The form says child and parent include in loco parentis relationships, and no legal or biological relationship is needed.
Who fills in which part of the form?
Section I can be completed by the employee or the employer. Section II is completed and signed by the employee. Section III is completed and signed by the family member's health care provider.
How long do I have to return it?
The employer must allow at least 15 calendar days, unless that is not feasible despite your diligent, good faith efforts.
Do I have to use this exact form?
No. The Department of Labor's FMLA forms are optional. Employers must accept a complete and sufficient certification in any format, such as a letter on the health care provider's letterhead.
Where do I send WH-380-F?
To your employer. Do not send completed certifications to the Department of Labor.
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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.