HomeMy WebLinkAbout2021 FMLA Policyaly0,
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Document ID
Title
Family and Medical Leave Act
(FMLA)
Revision
Prepared By: Cynthia Watson
10/1/2021
Human Resources Director
Effective Date
Reviewed By:
10/1/2021 /
Manny Anon, City Attorney
Sign atur /
Approved By:
/
Paul Carlisle, City Manager
PURPOSE
Print Date
10/01/2021
Date Prepared
10/01/2021
Date Reviewed
09/10/2021
Date Approved
09/02/2021
The purpose of this policy is to provide employees with a general description of their FMLA rights. In the
event of any conflict between this policy and the applicable law, employees will be afforded all rights
required by law. If you have any questions, concerns or disputes with this policy, please contact the
Human Resources Department.
The City of Sebastian complies with the Family and Medical Leave Act (FMLA) and will grant up to 12
weeks of leave during a 12-month period to eligible employees (or up to 26 weeks of military caregiver
leave).
ELIGIBILITY
To be eligible for leave under this policy, employees must meet all of the following requirements:
1. Worked for a covered employer;
2. Have worked at least twelve (12) months for City of Sebastian;
3. Have worked at least 1,250 hours for City of Sebastian over the previous twelve (12) months from
the date the leave would commence;
4. Currently work at a location where there are at least fifty (50) employees within seventy-five (75)
miles.
EMPLOYMENT ELIGIBILITY
Employees must meet certain requirements to be eligible for FMLA leave benefits. The 12 months of
employment do not have to be consecutive. Employment periods prior to a break in service of 7 years or
more need not be counted, unless the break is associated with the employee's fulfillment of his/her
National Guard or Reserve military obligation, or a written agreement exists indicating the employer's
intention to rehire the employee after the break in service. Thus, all periods of absence from work due to
or necessitated by service in the uniformed services are counted as hours worked in determining
eligibility.
REASONS FOR LEAVE
To qualify as FMLA leave under this policy, the leave must be for one of the following reasons:
1. The birth and care of a newborn child of the employee;
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2. For incapacity due to pregnancy, prenatal medical care or child birth;
3. The placement with the employee of a son or daughter for adoption or foster care;
4. To care for an immediate family member (spouse, child or parent) with a serious health condition;
5. For a serious health condition that makes the employee unable to perform the essential functions
of his or her job;
6. For any qualifying exigency arising out of the fact that a spouse, child or parent is a military
member on covered active duty or call to covered active duty status; or
7. To care for a covered service member with a serious injury or illness.
AMOUNT OF LEAVE
An eligible employee can take up to 12 weeks of FMLA leave during any 12-month period. The City will
measure the 12-month period as a calendar 12-month period. Each time an employee takes leave, the
City will compute the amount of leave the employee has taken under this policy in the last 12 months and
subtract it from the 12 weeks of available leave, and the balance remaining is the amount the employee is
entitled to take at that time.
An eligible employee can take up to 26 weeks for the FMLA military caregiver leave during a single 12-
month period. For this military caregiver leave, the City will measure the 12-month period as a calendar
year. FMLA leave already taken for other FMLA circumstances will be deducted from the total of 26
weeks available.
Eligible spouses who both work for the City may only take a combined total of 12 weeks of leave for the
birth of a child, adoption or placement of a child in foster care, or to care for a parent (but not a parent "in-
law") with a serious health condition. Both may only take a combined total of 26 weeks of leave to care for
a covered injured or ill service member (if each spouse is a parent, spouse, child or next of kin of the
service member).
INTERMITTENT LEAVE OR A REDUCED WORK SCHEDULE
Employees may take FMLA leave in one consecutive block of time, may use the leave intermittently (take
a day periodically when needed over the year) or, under certain circumstances, may use the leave to
reduce the workweek or workday, resulting in a reduced hour schedule. In all cases, the leave may not
exceed a total of 12 workweeks (480 hours) (or 26 workweeks to care for an injured or ill service member)
in a 12-month period.
The City may temporarily transfer an employee to an available alternative position with equivalent pay
and benefits if the alternative position would better accommodate the intermittent or reduced schedule, in
instances when leave for the employee or employee's family member is foreseeable and for planned
medical treatment, including recovery from a serious health condition or to care for a child after birth or
placement for adoption or foster care.
FMLA leave may be taken intermittently/reduced schedule whenever medically necessary to care for
a seriously ill family member, or because the employee is seriously ill and unable to work.
Only the amount of leave actually taken while on intermittent/reduced schedule leave may be charged as
FMLA leave. Employees may not be required to take more FMLA leave than necessary to address
the circumstances that cause the need for leave.
For the birth, care or placement for adoption or foster care of a child, the City and the employee must
mutually agree to the schedule before the employee may take the leave intermittently or work a reduced-
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hour schedule. Leave for birth, adoption or foster care of a child must be taken within one year of the birth
or placement of the child.
When leave is needed for planned medical treatment, the employee must make a reasonable effort to
schedule treatment so as not to unduly disrupt the City's operations.
EMPLOYEE NOTICE AND CERTIFICATION REQUIREMENT
Employees must provide thirty (30) days advance notice of the need to take leave. All employees
requesting FMLA leave must provide verbal or written notice of the need for leave to the Department
Director or Human Resources Director when they are absent from work for three or more consecutive
work days on sick leave.
If thirty (30) day notice is not possible, the employee must provide notice as soon as practicable and
generally must comply with an employer's normal call -in procedures. Employees must provide sufficient
information to the employer to determine if the leave may qualify for FMLA protection and provide the
anticipated timing and duration of the leave. When an employee becomes aware of a need for FMLA
leave fewer than thirty (30) days in advance, the employee must provide notice of the need for the leave
either the same day the need for leave is discovered or the next business day. When the need for FMLA
leave is not foreseeable, the employee must comply with the City's usual and customary notice and
procedural requirements for requesting leave, absent unusual circumstances.
Employees must also inform the employer if the requested leave is for a reason for which FMLA leave
was previously taken or certified. Employees may also be required to provide a certification and periodic
recertification to support the need for leave.
Within five (5) business days after the employee has provided this notice, the Human Resources Director
will complete and provide the employee with a Notice of Eligibility and Rights (Exhibit 1); request an
Employee/Family Member Medical Certfcation (Exhibits 2 and 3), supporting the need for leave due to
a serious health condition affecting the employee or his/her spouse, child, or parent; and other supporting
documentation, as necessary.
If the employee fails to provide timely notice, the FMLA leave request may be delayed or denied and
may be subject to whatever discipline the employer's rules provide.
DESIGNATION OF FMLA LEAVE
Within five (5) business days after the employee has submitted the required certification or other
documentation, the Human Resources Director will complete and provide the employee with a written
response to the employee's request for FMLA leave using the FMLA Designation Notice (Exhibit 4).
EMPLOYEE STATUS AND BENEFITS DURING LEAVE
City of Sebastian will continue an employee's health benefits during the leave period at the same level
and under the same conditions as if the employee was continuously at work.
While on paid leave the employer will continue to make payroll deductions to collect the employee's
share of insurance premiums. While on unpaid leave, the employee must continue to make its share
of insurance premium payments, either in person or by mail. The payment must be received in the
Administrative Services Department by the 20th day of each month.
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If the payment is more than thirty (30) days late, the employee's health care coverage may be terminated
during the FMIA leave for failure by the employee to maintain his/her contributions.
The City will provide fifteen (15) days notification prior to the employee's loss of coverage.
If the employee chooses not to return to work for reasons other than a continued serious health condition
of the employee or the employee's family member or a circumstance beyond the employee's control, the
City will require the employee to reimburse the City the amount it paid for the employee's health
insurance premium during the leave period.
If the employee contributes to a life insurance or disability plan, the City will continue making payroll
deductions while the employee is on paid leave. While the employee is on unpaid leave, the employee
may request continuation of such benefits and pay his or her portion of the premiums, or the City may
elect to maintain such benefits during the leave and pay the employee's share of the premium payments.
If the employee does not continue these payments, the City will discontinue coverage during the leave. If
the City maintains coverage, the City may recover the costs incurred for paying the employee's share of
any premiums, whether or not the employee returns to work.
EMPLOYEE STATUS AFTER LEAVE — FITNESS FOR DUTY CERTIFICATION
FMIA regulations allow employers to enforce uniformly applied policies or practices that require all
similarly situated employees who take leave to provide certification that they are able to resume and
return to work. This requirement will be included in the City's response to the FMLA request.
An employee who takes leave under this policy may be asked to provide a fitness for duty clearance from
a health care provider for the following reasons: First, an employee may require that the certification
specifically address the employee's ability to perform the essential functions of the employee's job.
Second, where reasonable job safety concerns exist, an employer may require a fitness -for -duty
certification before an employee may return to work when the employee takes intermittent leave.
Generally, an employee who takes FMIA leave will be able to return to the same position or a position
with equivalent status, pay, benefits and other employment terms. The position will be the same or one
that is virtually identical in terms of pay, benefits and working conditions. The City may choose to exempt
certain key employees from this requirement and not return them to the same or similar position when
doing so will cause substantial and grievous economic injury to business operations. Key employees will
be given written notice at the time FMLA leave is requested of his or her status as a key employee.
USE OF PAID AND UNPAID LEAVE
An employee who is taking FMLA leave because of the employee's own serious health condition or the
serious health condition of a family member must use all paid sick leave, personal or vacation leave prior
to being eligible for unpaid leave. Sick leave will run concurrently with FMLA leave if the reason for the
FMLA leave is covered by the established sick leave policy. If their accrued paid leave benefits are
exhausted, employees may take unpaid FMLA leave until the conclusion of the approved leave.
Employees on Workers' Compensation leave (to the extent that they qualify), that runs concurrently with
their FMLA leave, are not required to use their accrued paid leave benefits.. An employee who is taking
leave for the adoption or foster care of a child must use all paid vacation or personal prior to being eligible
for unpaid leave.
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An employee who is using military FMLA leave for a qualifying exigency must use all paid sick, vacation
and personal leave prior to being eligible for unpaid leave. An employee using FMLA military caregiver
leave must also use all paid sick, personal leave or vacation leave (as long as the reason for the absence
is covered by the City's sick leave policy) prior to being eligible for unpaid leave.
The City of Sebastian will determine if an employee's use of paid leave counts as FMLA leave, based
upon information received from the employee.
INTENT TO RETURN TO WORK FROM FMLA LEAVE
On a basis that does not discriminate against employees on FMLA leave, the City requires an employee
on FMLA leave to report periodically on the employee's status and intent to return to work.
WHEN A HOLIDAY FALLS IN FMLA
When a holiday falls during a week in which an employee is taking the full week of FMLA leave, the entire
week is counted as FMLA leave. However, when a holiday falls during a week when an employee is
taking less than the full week of FMLA leave, the holiday is not counted as FMLA leave, unless the
employee was scheduled and expected to work on the holiday and used FMLA leave for that day.
EMPLOYEE'S RESPONSIBILITY WHILE ON LEAVE
1. An employee granted a leave of absence in excess of twelve (12) weeks shall contact his/her
department and inform his/her Director, or designee, on a monthly basis, (unless other reporting
arrangements have been approved in advance), of his/her current status and intent to return to
work.
2. An employee on a leave of absence shall keep his/her department advised of any change in
his/her current address and telephone number, if applicable.
3. An employee who is granted a leave of absence must notify and make arrangements with the
Human Resources Department prior to the effective date of the leave and advise if they wish to
continue or discontinue any form of group insurance coverage.
4. Extensions requested by the employee beyond the twelve (12) weeks must be requested in
writing and require the approval of the Department Head, the Human Resources Director and City
Manager.
RETURN FROM LEAVE OF ABSENCE/JOB RESTORATION
1. An employee who returns to work within the twelve (12) week entitlement will be returned to the
same position. If circumstances have changed so as to make that impossible or unreasonable as
determined by the City Manager or Human Resources Director, the employee shall be placed in
an equivalent position with equivalent benefits, pay and other terms and conditions of
employment.
2. An employee who has utilized the twelve (12) week entitlement and is granted an extension shall
be permitted to return to work to his/her prior position or classification providing a vacancy exists
and he/she is able to perform the essential functions of the job with or without accommodation. If
a vacancy does not exist, the City shall make a reasonable effort to transfer him/her within thirty
(30) calendar days to a position for which he/she is qualified. If no positon is available, he/she
shall be terminated and shall be eligible for reinstatement to his/her classification for a period of
one (1) year.
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3. An employee wishing to return to work from a medical leave of absence is required to provide the
Department Head with a one (1) week notice prior to his/her requested date of return, to include a
fitness for duty certification from the health care provider that he/she is available to resume all of
the essential functions of his/her position, including regular attendance and is fit for duty. The
City has a right to request a second or third examination, at the City's expense, prior to approving
the employee's return to work. The City shall not be responsible for the employee's time and
incidental expenses. Restoration will be denied by the employer if the employee fails to provide
the required fitness for duty certification.
4. An employee may voluntarily return to work by accepting a light duty assignment. By doing so,
however, the employee could exhaust restoration rights under FMLA prior to FMLA time being
exhausted.
5. Also, an employee under a workers' compensation leave that is running concurrently with his/her
FMLA leave, could forfeit workers' compensation benefits if he/she refuses a light duty
assignment offered by the employer in conjunction with the workers' compensation claim.
6. An employee's use of FMLA leave cannot result in the loss of any employee benefit that the
employee earned or was entitled to before using FMLA leave, nor be counted against the
employee under a "no fault" attendance policy.
7. Under specified and limited circumstances where restoration to employment will cause
substantial and grievous economic injury to its operations, an employer may refuse to reinstate
certain highly paid "key" employees after using FMLA leave during which health coverage
was maintained. A "key" employee is a salaried "eligible" employee who is among the highest ten
percent of employees compensated, within 75 miles of the work site.
8. Benefits and protection under the FMLA leave end if the employee fails to return to work within
the 2-week entitlement, therefore, the employee is not entitled to restoration under FMLA.
UNLAWFUL ACTS BY EMPLOYERS
FMLA makes it unlawful for any employer to:
1. Interfere with, restrain, or deny the exercise of any right provided under FMLA.
2. Discharge or discriminate against any person for opposing any practice made unlawful by, FMLA
or for involvement in any proceeding under or relating to FMLA.
ENFORCEMENT
The Wage and Hour Division investigates complaints. If violations cannot be satisfactorily resolved, the
U.S. Department of Labor is authorized to investigate, resolve complaints of violations and bring action in
court to compel compliance. An eligible employee may also bring civil action against an employer for
violations. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any
State or Local law or collective bargaining agreement which provides greater family or medical leave
rights.
DEFINITIONS
Serious health condition means an illness, injury, impairment, or physical or mental condition that
involves inpatient care or continuing treatment by a health care provider. This can include conditions with
short-term, chronic, long-term or permanent periods of incapacity.
Spouse means a husband or wife as defined or recognized in the state where the individual was married
and includes individuals in a common law or same -sex marriage. Spouse also includes a husband or wife
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in a marriage that was validly entered into outside of the United States, if the marriage could have been
entered into in at least one state.
Child means a biological, adopted or foster child, a stepchild, a legal ward, or a child of a person standing
in loco parentis, who is either under age 18, or age 18 or older and "incapable of self -care because of a
mental or physical disability" at the time that FMLA leave is to commence.
Parent means a biological, adoptive, step or foster father or mother, or any other individual who stood in
loco parentis to the employee when the employee was a child. This term does not include parents "in
law."
Qualifying exigency includes short -notice deployment, military events and activities, child care and
school activities, financial and legal arrangements, counseling, rest and recuperation, post -deployment
activities, and additional activities that arise out of active duty, provided that the employer and employee
agree, including agreement on timing and duration of the leave.
Covered active duty for members of a regular component of the Armed Forces, means duty during
deployment of the member with the Armed Forces to a foreign country. For a member of the Reserve
components of the Armed Forces, means duty during the deployment of the member with the Armed
Forces to a foreign country under a federal call or order to active duty in support of a contingency
operation, in accordance with 29 CR 825.102.
The next of kin of a covered service member is the nearest blood relative, other than the covered
service member's spouse, parent or child in the following order of priority: blood relatives who have been
granted legal custody of the service member by court decree or statutory provisions, brothers and sisters,
grandparents, aunts and uncles, and first cousins, unless the covered service member has specifically
designated in writing another blood relative as his or her nearest blood relative for purposes of military
caregiver leave under the FMLA.
Covered service member is a current member of the Armed Forces, including a member of the National
Guard or Reserves, who is receiving medical treatment, recuperation or therapy, or is in outpatient status
or on the temporary disability retired list for a serious injury or illness.
Serious injury or illness is one that is incurred by a service member in the line of duty on active duty
that may cause the service member to be medically unfit to perform the duties of his or her office, grade,
rank or rating. A serious injury or illness also includes injuries or illnesses that existed before the service
member's active duty and that were aggravated by service in the line of duty on active duty.
For additional Information
Contact the nearest office of Wage and Hour Division
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
200 Constitution Ave., NW
Washington, DC 20210
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CITY OF SEBASTIAN
RECEIPT OF FAMILY MEDICAL LEAVE POLICY
This will acknowledge my receipt of the City of Sebastian's Family Medical Leave Policy. I have read
this policy and understand its contents. I will contact my supervisor or the Human Resources Department
for clarification if at any time in the future I do not understand any portion of this policy. I agree to be
responsible for any revisions and/or updates to the Policy and for deletion of any obsolete material
therein, which I receive.
I recognize that this policy is not a contractual document, and that none of its provisions constitute
contractual terms or conditions of employment. I also recognize that the City Manager may alter,
supplement, delete or amend any portion of this policy at any time at his/her sole discretion.
My signature attests to the fact that I have read this Policy, that I am familiar with its contents, and that I
will act accordingly.
Employee's Signature
Name (Printed)
Date
Certification for Serious Injury or Illness of a
Current Servicemember for Military Caregiver Leave
under the Family and Medical Leave Act
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR.
RETURN TO THE PATIENT.
U.S. Department of Labor
Wage Hour Division orftw N a
WAGE AND HOUR DIVISION
OMB Control Number: 1235-0003
Expires: 6/30/2023
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave to care for a covered
servicemember with a serious illness or injury. The FMLA allows an employer to require an employee seeking FMLA leave
for this purpose to submit a medical certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the employee at
least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient certification,
his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the
WHD website at www.dol.2ov/a2encies/whd/fmla.
SECTION I - EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, it asks the health care
provider for the information necessary for a complete and sufficient medical certification. You may not ask the employee
to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310. Recertifications are
not allowed for FMLA leave to care for a covered servicemember. Where medical certification is requested by an
employer, an employee may not be held liable for administrative delays in the issuance of military documents, despite
the employee's diligent, good -faith efforts to obtain such documents. An employer requiring an employee to submit a
certification for leave to care for a covered servicemember must accept as sufficient certification invitational travel orders
(ITOs) or invitational travel authorizations (ITAs) issued to any family member to join an injured or ill servicemember at
the servicemember's bedside. An ITO or ITA is sufficient certification for the duration of time specified in the ITO or ITA.
Employers must generally maintain records and documents relating to medical information, medical certifications,
recertifications, or medical histories of employees or employees' family members created for FMLA purposes as
confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. §
1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic
Information Nondiscrimination Act applies.
(1) Employee name:
(2) Employer name:
First Middle Last
Date: (mm/dd/yyyy)
(List date certification requested)
(3) This certification must be returned by: (mm/dd/yyyy)
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee's diligent, good faith efforts.)
SECTION II - EMPLOYEE and/or CURRENT SERVICEMEMBER —9WW
Please complete all Parts of Section II before having the servicemember's health care provider complete Section III. The
FMLA allows an employer to require that an employee submit a timely, complete, and sufficient certification to support a
request for FMLA leave due to a serious injury or illness of a covered servicemember. If requested by your employer, your
response is required to obtain or retain the benefit of FMLA-protected leave.
PART A: EMPLOYEE INFORMATION
(1) Name of the current servicemember for whom employee is requesting leave:
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Employee Name:
(2) Select your relationship to the current servicemember. You are the current servicemember's:
0 Spouse 0 Parent 0 Child 0 Next of Kin
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common law
marriage or same -sex marriage. The terms "child" and "parent" include in loco parentis relationships in which a person assumes the
obligations of a parent to a child. An employee may take FMLA leave to care for a covered servicemember who assumed the obligations
of a parent to the employee when the employee was a child. An employee may also take FMLA leave to care for a covered
servicemember for whom the employee has assumed the obligations of a parent. No biological or legal relationship is necessary. "Next
of kin" is the servicemember's nearest blood relative, other than the spouse, parent, son, or daughter, in the following order of priority:
(1) a blood relative as designated in writing by the servicemember for purposes of FMLA leave, (2) blood relatives granted legal custody
of the servicemember, (3) brothers and sisters, (4) grandparents, (5) aunts and uncles, and (6) first cousins.
PART B: SERVICEMEMBER INFORMATION AND CARE TO BE PROVIDED TO THE SERVICEMEMBER
(3) The servicemember (0 is / 0 is not) a current member of the Regular Armed Forces, the National Guard or
Reserves. If yes, provide the servicemember's military branch, rank and unit currently assigned to:
(4) The servicemember (13 is / O is not) assigned to a military medical treatment facility as an outpatient or to a unit
established for the purpose of providing command and control of members of the Armed Forces receiving medical
care as outpatients, such as a medical hold or warrior transition unit. If yes, provide the name of the medical treatment
facility or unit:
(5) The servicemember (0 is / 0 is not) on the Temporary Disability Retired List (TDRL).
(6) Briefly describe the care you will provide to the servicemember: (Check all that apply)
❑ Assistance with basic medical, hygienic, nutritional, or safety needs
❑ Psychological Comfort
❑ Transportation
❑ Physical Care
❑ Other:
(7) Give your best estimate of the amount of leave needed to provide the care described:
(8) If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work
schedule you are able to work. From
able to work:
(mm/dd/yyyy) to
(hours per day)
SECTION III - HEALTH CARE PROVIDER
(mm/dd/yyyy), I am
(days per week).
Please provide your contact information, complete all Parts of this Section fully and completely, and sign the form below.
The employee listed at Section I has requested leave under the FMLA to care for a family member who is a current member
of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or
therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness.
Note: For purposes of FMLA leave, a serious injury or illness is one that was incurred in the line of duty on active duty in
the Armed Forces or that existed before the beginning of the member's active duty and was aggravated by service in the
line of duty on active duty in the Armed Forces that may render the servicemember medically unfit to perform the duties of
the servicemember's office, grade, rank, or rating. "Need for care" includes both physical and psychological care. It includes
situations where, for example, due to his or her serious injury or illness, the servicemember is not able to care for his or her
own basic medical, hygienic, or nutritional needs or safety, or needs transportation to the doctor. It also includes providing
psychological comfort and reassurance which would be beneficial to the servicemember who is receiving inpatient or home
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Employee Name:
care. A complete and sufficient certification to support a request for FMLA leave due to a current servicemember's serious
injury or illness includes written documentation confirming that the servicemember's injury or illness was incurred in the
line of duty on active duty or if not, that the current servicemember's injury or illness existed before the beginning of the
servicemember's active duty and was aggravated by service in the line of duty on active duty in the Armed Forces, and that
the current servicemember is undergoing treatment for such injury or illness by a health care provider listed above.
PART A: HEALTH CARE PROVIDER INFORMATION
Health Care Provider's Name: (Print)
Health Care Provider's business address:
Type of practice/Medical specialty:
Telephone: O Fax: E-mail:
Please select the type of FMLA health care provider you are:
❑ DOD health care provider
❑ VA health care provider
❑ DOD TRICARE network authorized private health care provider
❑ DOD non -network TRICARE authorized private health care provider
❑ Health care provider as defined in 29 C.F.R. § 825.125
PART B: MEDICAL INFORMATION
Please provide appropriate medical information of the patient as requested below. Limit your responses to the
servicemember's condition for which the employee is seeking leave. If you are unable to make some of the military -related
determinations contained below, you are permitted to rely upon determinations from an authorized DOD representative,
such as a DOD recovery care coordinator. Do not provide information about genetic tests, as defined in 29 C.F.R. §
1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e).
(1) Patient's Name:
(2) List the approximate date condition started or will start: (--Idd/yyyy)
(3) Provide your best estimate of how long the condition will last:
(4) The servicemember's injury or illness: (Select as appropriate)
0 Was incurred in the line of duty on active duty.
❑ Existed before the beginning of the servicemember's active duty and was
aggravated by service in the line of duty on active duty.
0 None of the above.
(5) The servicemember (E3 is / 0 is not) undergoing medical treatment, recuperation, or therapy for this condition.
If yes, briefly describe the medical treatment, recuperation or therapy:
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Employee Name:
(6) The current servicemember's medical condition is classified as: (Select as appropriate)
❑ (VSI) Very Seriously IIl/Injured Illness/Injury is of such a severity that life is imminently endangered. Family
members are requested at bedside immediately. Please note this is an internal DOD casualty assistance designation
used by DOD healthcare providers.
❑ (SI) Seriously III/Injured Illness/injury is of such severity that there is cause for immediate concern, but there
is no imminent danger to life. Family members are requested at bedside. Please note this is an internal DOD
casualty assistance designation used by DOD healthcare providers.
❑ OTHER Ill/Injured A serious injury or illness that may render the servicemember medically unfit to perform
the duties of the member's office, grade, rank, or rating.
❑ NONE OF THE ABOVE. Note to Employee: If this box is checked, you may still be eligible to take leave to care for
a covered family member with a "serious health condition " under 29 C.F.R. § 825.113 of the FMLA. If such leave is
requested, you may be required to complete DOL FORM WH-380-F or an employer provided form seeking the same
information.
PART C: AMOUNT OF LEAVE NEEDED
For the medical condition checked in Part B, complete all that apply. Some questions seek a response as to the frequency or duration of
a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination
of the patient. Be as specific as you can; terms such as "lifetime," "unknown," or "indeterminate" may not be sufficient to determine
FMLA coverage.
(7) Due to the condition, the servicemember will need care for a continuous period of time, including any time for
treatment and recovery. Provide your best estimate of the beginning date (mm/dd/yyyy) and
end date (mm/dd/yyyy) for this period of time.
(8) Due to the condition, it is medically necessary for the servicemember to attend planned medical treatment
appointments (scheduled medical visits). Provide your best estimate of the duration of the treatment(s), including
any period(s) of recovery (e.g. 3 days/week)
(9) Due to the condition, it is medically necessary for the servicemember to receive care on an intermittent basis
(periodically), such as the care needed because of episodic flare-ups of the condition or assisting with the
servicemember's recovery. Provide your best estimate of how often (frequency) and how long (the duration)
the intermittent episodes will likely last.
Over the next 6 months, intermittent care is estimated to occur
(0 day / 0 week / E3 month) and are likely to last approximately
episode.
Signature of
Health Care Provider
times per
(0 hours / 0 days) per
Date (mm/dd/yyyy)
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, in accordance with 29
U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number. The Department of Labor estimates that it will take an average of 15 minutes for respondents to complete
this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate
or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage
and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN IT TO THE PATIENT.
Page 4 of 4 Form WH-385, Revised June 2020
Certification for Serious Injury or Illness of a U.S. Department of Labor 04WHO
Veteran for Military Caregiver Leave Wage and Hour Division
under the Family and Medical Leave Act
WAGE AND HOUR DIVISION
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003
RETURN TO THE PATIENT. Expires: 6/30/2023
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave to care for a covered
veteran with a serious illness or injury. The FMLA allows an employer to require an employee seeking FMLA leave for
this purpose to submit a medical certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the employee at
least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient certification,
his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the
WHD website at www.dol.gov/agencies/whd/fmla.
SECTION I — EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, it asks the health care
provider for the information necessary for a complete and sufficient medical certification. Recertifications are not allowed
for FMLA leave to care for a covered servicemember. Where medical certification is requested by an employer, an
employee may not be held liable for administrative delays in the issuance of military documents, despite the
employee's diligent, good -faith efforts to obtain such documents. In lieu of this form or your own certification form, you
must accept as sufficient certification of the veteran's serious injury or illness documentation indicating the veteran's
enrollment in the Department of Veterans Affairs Program of Comprehensive Assistance for Family Caregivers. You may
not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310.
Employers must generally maintain records and documents relating to medical information, medical certifications,
recertifications, or medical histories of employees or employees' family members, created for FMLA purposes as
confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. §
1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic
Information Nondiscrimination Act applies.
(1) Employee name:
First
Middle
Last
(2) Employer Name: Date: (mm/dd/yyyy)
(List date certification requested)
(3) This certification must be returned by: (mm/dd/yyyy)
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee's diligent, good faith efforts)
SECTION II - EMPLOYEE and/or VETERAN FMMEF
Please complete all Parts in Section II before having the veteran's health care provider complete Section 111. The FMLA
allows an employer to require that an employee submit a timely, complete, and sufficient certification to support a request
for military caregiver leave under the FMLA due to a serious injury or illness of a covered veteran. If requested by the
employer, your response is required to obtain or retain the benefit of FMLA-protected leave. The employer must give an
employee at least 15 calendar days to return this form to the employer. 29 U.S.C. §§ 2613, 2614(c)(3).
PART A: EMPLOYEE INFORMATION
(1) Name of veteran for whom employee is requesting leave:
First
Middle
Last
Page 1 of 4 Form WH-385-V, Revised June 2020
Employee Name:
(2) Select your relationship to the veteran. You are the veteran's:
0 Spouse 0 Parent 0 Child 0 Next of Kin
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common law
marriage or same -sex marriage. The terms "child" and "parent" include in loco parentis in which a person assumes the obligations of a
parent to a child. An employee may take FMLA leave to care for a covered servicemember who assumed the obligations of a parent to
the employee when the employee was a child. An employee may also take FMLA leave to care for a covered servicemember for whom
the employee has assumed the obligations of a parent. No biological or legal relationship is necessary. "Next of kin" is the veteran's
nearest blood relative, other than the spouse, parent, son, or daughter, in the following order of priority: (1) a blood relative as designated
in writing by the veteran for purposes of FMLA leave, (2) blood relatives granted legal custody of the veteran, (3) brothers and sisters,
(4) grandparents, (5) aunts and uncles, and (6) first cousins.
PART B: VETERAN INFORMATION AND CARE TO BE PROVIDED TO THE VETERAN
(3) The veteran was (0 honorably / 0 dishonorably) discharged or released from the Armed Forces, including the National
Guard or Reserves. List the date of the veteran's discharge: (mm/dd/yyyy)
(4) Please provide the veteran's military branch, rank and unit at the time of discharge:
(5) The veteran ([3 is / 0 is not) receiving medical treatment, recuperation, or therapy for an injury or illness.
(6) Briefly describe the care you will provide to the veteran: (Check all that apply)
❑ Assistance with basic medical, hygienic, nutritional, or safety needs ❑ Transportation
❑ Psychological Comfort ❑ Physical Care ❑ Other:
(7) Give your best estimate of the amount of FMLA leave needed to provide the care described:
(8) If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work
schedule you are able to work. From (mm/dd/yyyy) to (mm/dd/yyyy) I am
able to work: (hours per day) (days per week).
SECTION III - HEALTH CARE PROVIDER
Please provide your contact information, complete all Parts of this Section fully and completely, and sign the form below.
The employee named in Section I has requested leave under the military caregiver leave provision of the FMLA to care for
a family member who is a veteran.
Note: For purposes of FMLA military caregiver leave, a serious injury or illness means an injury or illness incurred by the
servicemember in the line of duty on active duty in the Armed Forces (or that existed before the beginning of the
servicemember's active duty and was aggravated by service in the line of duty on active duty in the Armed Forces) and
manifested itself before or after the servicemember became a veteran, and is: a continuation of a serious injury or illness
that was incurred or aggravated when the covered veteran was a member of the Armed Forces and rendered the
servicemember unable to perform the duties of the servicemember's office, grade, rank, or rating; or a physical or mental
condition for which the covered veteran has received a U.S. Department of Veterans Affairs Service Related Disability
Rating (VASRD) of 50 percent or greater, and such VASRD rating is based, in whole or in part, on the condition
precipitating the need for military caregiver leave; or a physical or mental condition that substantially impairs the covered
veteran's ability to secure or follow a substantially gainful occupation by reason of a disability or disabilities related to
military service, or would do so absent treatment; or an injury, including a psychological injury, on the basis of which the
covered veteran has been enrolled in the Department of Veterans' Affairs Program of Comprehensive Assistance for Family
Caregivers.
Page 2 of 4 Form WH-385-V, Revised June 2020
Employee Name:
"Need for care" includes both physical and psychological care. It includes situations where, for example, due to his or her
serious injury or illness, the veteran is not able to care for his or her own basic medical, hygienic, or nutritional needs or
safety, or needs transportation to the doctor. It also includes providing psychological comfort and reassurance which would
be beneficial to the veteran who is receiving inpatient or home care.
A complete and sufficient certification to support a request for FMLA military caregiver leave due to a covered veteran's
serious injury or illness includes written documentation confirming that the veteran's injury or illness was incurred in the
line of duty on active duty or existed before the beginning of the veteran's active duty and was aggravated by service in the
line of duty on active duty, and that the veteran is undergoing treatment, recuperation, or therapy for such injury or illness
by a health care provider listed above. Information about the FMLA may be found on the WHD website
at www.dol.gov/agencies/whd/ftnla.
PART A: HEALTH CARE PROVIDER INFORMATION
Health Care Provider's Name: (Print)
Health Care Provider's business address:
Type of Practice/Medical Specialty:
Telephone: (__) Fax: (_) E-mail:
Please select the type of FMLA health care provider you are:
❑ DOD health care provider
❑ VA health care provider
❑ DOD TRICARE network authorized private health care provider
❑ DOD non -network TRICARE authorized private health care provider
❑ Health care provider as defined in 29 CFR 825.125
PART B: MEDICAL INFORMATION
Please provide appropriate medical information of the patient as requested below. Limit your responses to the veteran's
condition for which the employee is seeking leave. If you are unable to make certain military -related determinations
contained below, you are permitted to rely upon determinations from an authorized DOD representative, such as a DOD
Recovery Care Coordinator, or an authorized VA representative. Do not provide information about genetic tests, as defined
in 29 C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e).
(1) Patient's Name:
(2) List the approximate date condition started or will start: (mm/dd/yyyy)
(3) Provide your best estimate of how long the condition will last:
(4) The veteran's injury or illness: (Select as appropriate)
0 Was incurred in the line of duty on active duty
0 Existed before the beginning of the veteran's active duty and was aggravated by
service in the line of duty on active duty
0 None of the above
The veteran (0 is / 0 is not) undergoing medical treatment, recuperation, or therapy for this condition. If yes, briefly
describe the medical treatment, recuperation, or therapy:
Page 3 of 4 Form WH-385-V, Revised June 2020
Employee Name:
(5) The veteran's medical condition is: (Select as appropriate)
❑ A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member
of the Armed Forces and rendered the servicemember not able to perform the duties of the servicemember's office,
grade, rank, or rating.
❑ A physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs
Service Related Disability Rating (VASRD) of 50% or higher, and such VASRD rating is based, in whole or in part,
on the condition precipitating the need for military caregiver leave.
❑ A physical or mental condition that substantially impairs the covered veteran's ability to secure or follow a
substantially gainful occupation by reason of a disability or disabilities related to military service, or would do so
absent treatment.
❑ An injury, including a psychological injury, on the basis of which the covered veteran is enrolled in the Department
of Veterans' Affairs Program of Comprehensive Assistance for Family Caregivers.
❑ None of the above. Note to Employee: If this box is checked, you may still be eligible to take leave to care for a covered
family member with a "serious health condition " under 29 C.F.R. § 825.113 of the FMLA. If such leave is requested, you
may be required to complete DOL FORM WH-380-F or an employer provided form seeking the same information.
Part C: Amount of Leave Needed
For the medical condition checked in Part B, complete all that apply. Some questions seek a response as to the frequency or
duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge,
experience, and examination of the patient. Be as specific as you can; terms such as "lifetime," "unknown," or
"indeterminate" may not be sufficient to determine FMLA military caregiver leave coverage.
(1) Due to the condition, the veteran will need care for a continuous period of time, including any time for treatment and
recovery. Provide your best estimate of the beginning date (mm/dd/yyyy) and end date
(mm/dd/yyyy) for this period of time.
(2) Due to the condition, it is medically necessary for the veteran to attend planned medical treatment appointments (scheduled
medical visits). Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery
(e.g. 3 days/week)
(3) Due to the condition, it is medically necessary for the veteran to receive care on an intermittent basis (periodically), such
as the care needed because of episodic flare-ups of the condition or assisting with the veteran's recovery. Provide your best
estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.
Over the next 6 months, intermittent care is estimated to occur times per (0 day / O week / [3 month)
and are likely to last approximately (O hours / O days) per episode.
Signature of
Health Care Provider
Date (mm/dd/yyyy)
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, in accordance with
29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number. The Department of Labor estimates that it will take an average of 15 minutes for respondents to complete
this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate
or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage
and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, NW, Washington, DC 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
Page 4 of 4 Form WH-385-V, Revised June 2020
Certification for Military Family Leave for U.S. Department of Labor 004WHO
Qualifying Exigency Wage and Hour Division
under the Family and Medical Leave Act WAGE AND HOUR DIVISION
DO NOT SEND FORM TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003
RETURN THE COMPLETED FORM TO THE EMPLOYER. Expires: 6/30/2023
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave for a qualifying
exigency while the employee's spouse, child, or parent (the military member) is on covered active duty or has been notified
of an impending call or order to covered active duty. The FMLA allows an employer to require an employee seeking FMLA
leave due to a qualifying exigency to submit a certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the
employee at least 15 calendar days to provide the certification. 29 C.F.R. § 825.305(b). If the employee fails to provide
complete and sufficient certification, the employee's FMLA leave request may be denied. 29 C.F.R. § 825.313. Information
about the FMLA may be found on the WHD website at httD://www.dol.2ov/a2encies/whd/fmla.
SECTION I - EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, it asks the employee for
the information necessary for a complete and sufficient qualifying exigency certification, which is set out at 29 C.F.R. §
825.309. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29
C.F.R. § 825.309.
(1) Employee name:
(2) Employer name:
First Middle Last
Date: (mm/dd/yyyy)
(List date certification requested)
(3) This certification must be returned by (mm/dd/yyyy).
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee's diligent, good faith efforts)
SECTION II - EMPLOYEE 9MEME
Please complete all Parts of Section II and sign the form before returning it to your employer. The FMLA allows an employer
to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a
qualifying exigency. If requested by your employer, your response is required to obtain the benefits and protections of the
FMLA. 29 C.F.R. § 825.309. Failure to provide a complete and sufficient certification may result in a denial of your FMLA
leave request. A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency
includes written documentation confirming a military member's covered active duty or call to covered active duty status.
You are responsible for making sure the certification is provided to your employer within the time frame requested,
which must be at least 15 calendar days. 29 C.F.R. § 825.313.
(1) Provide the name of the military member on covered active duty or call to covered active duty status:
First
Middle
Last
(2) Select your relationship of the military member. The military member is your:
E3 Spouse 0 Parent [3 Child, of any age
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common
law marriage or same -sex marriage. The terms "child" and "parent" include in loco parentis relationships in which a person
assumes the obligations of a parent to a child. An employee may take FMLA leave for a qualifying exigency related a military
member who assumed the obligations of a parent to the employee when the employee was a child. An employee may also take
FMLA leave for a qualifying exigency related a military member for whom the employee has assumed the obligations of a
parent. No legal or biological relationship is necessary.
Page 1 of 4 Form WH-384, Revised June 2020
Employee Name:
PART A: COVERED ACTIVE DUTY STATUS
Covered active duty or call to covered active duty in the case of a member of the Regular Armed Forces means duty during
the deployment of the member with the Armed Forces to a foreign country. Covered active duty or call to covered active
duty in the case of a member of the Reserve components means duty during the deployment of the member with the Armed
Forces to a foreign country under a Federal call or order to active duty in support of a contingency operation pursuant to:
Section 688 of Title 10 of the United States Code; Section 12301(a) of Title 10 of the United States Code; Section 12302
of Title 10 of the United States Code; Section 12304 of Title 10 of the United States Code; Section 12305 of Title 10 of
the United States Code; Section 12406 of Title 10 of the United States Code; chapter 15 of Title 10 of the United States
Code; or, any other provision of law during a war or during a national emergency declared by the President or Congress
so long as it is in support of a contingency operation. 10 U.S.C. § 101(a)(13)(B).
An employer may require the employee to provide a copy of the military member's active duty orders or other
documentation issued by the military which indicates that the military member is on covered active duty or call to covered
active duty status, and the dates of the military member's covered active duty service. This information need only be
provided to the employer once, unless additional leave is needed for a different military member or different
deployment.
(3) Provide the dates of the military member's covered active duty service:
(4) Please check one of the following and attach the indicated written document to support that the military member
is on covered active duty or call to covered active duty status:
0 A copy of the military member's covered active duty orders
Other documentation from the military indicating that the military member is on covered active duty or has
been notified of an impending call to covered active duty, such as official military correspondence from the
military member's chain of command
I have previously provided my employer with sufficient written documentation confirming the military
member's covered active duty or call to covered active duty status
PART B: APPROPRIATE FACTS
Under the FMLA, leave can be taken for a number of qualifying exigencies. 29 C.F.R. § 825.126(b). Complete and
sufficient certification to support a request for FMLA leave due to a qualifying exigency includes available written
documentation which supports the need for leave such as a copy of a meeting announcement for informational briefings
sponsored by the military, a document confirming the military member's Rest and Recuperation leave, or other
documentation issued by the military which indicates that the military member has been granted Rest and Recuperation
leave, or a document confirming an appointment with a third party (e.g., a counselor or school official, or staff at a care
facility, a copy of a bill for services for the handling of legal or financial affairs). Please provide appropriate facts related
to the particular qualifying exigency to support the FMLA leave request, including information on the type of qualifying
exigency and any available written documentation of the exigency event.
(5) Select the appropriate Qualifying Exigency Category and, if needed, provide additional information related to
the event:
❑ Short notice deployment (i.e., deployment within seven or fewer days of notice)
❑ Military events and related activities (e.g., official ceremonies or events, or family support and assistance programs):
❑ Childcare related activities for the child of the military member (e.g., arranging for alternative childcare):
Page 2 of 4 Form WH-384, Revised June 2020
Employee Name:
❑ Care for the military member's parent (e.g., admitting or transferring the parent to anew care facility):
❑ Financial and legal arrangements related to the deployment (e.g., obtaining military identification cards)
❑ Counseling related to the deployment (i.e., counseling provided by someone other than a health care provider)
❑ Military member's short-term, temporary Rest and Recuperation leave (R&R) (leave for this reason is limited
to 15 calendar days for each instance of R&R)
❑ Post deployment activities (e.g., arrival ceremonies, or reintegration briefings and events):
❑ Any other event that the employee and employer agree is a qualifying exigency:
(6) Available written documentation supporting this request for leave is (13 attached / 13 not attached / 0 not
available).
PART C: AMOUNT OF LEAVE NEEDED
Provide information concerning the amount of leave that will be needed. Several questions in this section seek a
response as to the frequency or duration of the qualifying exigency leave needed. Be as specific as you can; terms such as
"unknown " or "indeterminate " may not be sufficient to determine FMLA coverage.
(7) List the approximate date exigency started or will start:
(mm/dd/yyyy)
(8) Provide your best estimate of how long the exigency lasted or will last:
From (mm/dd/yyyy) to (mm/dd/yyyy)
(9) Due to a qualifying exigency, I need to work a reduced schedule. Provide your best estimate of the reduced
schedule you are able to work:
From (mm/dd/yyyy) to (mm/dd/yyyy)
I am able to work
(e.g., 5 hours/day, up to 25 hours a week)
(10) Due to a qualifying exigency, I will need to be absent from work for a continuous period of time. Provide your
best estimate of the beginning and ending dates for the period of absence:
From (mm/dd/yyyy) to (mm/dd/yyyy)
Page 3 of 4 Form WH-384, Revised June 2020
Employee Name:
(11) Due to a qualifying exigency, I will need to be absent from work on an intermittent basis (periodically).
Provide your best estimate of the frequency (how often) and duration (how long) of each appointment, meeting, or
leave event, including any travel time.
Over the next 6 months, absences on an intermittent basis are estimated to occur: times per
(O day / O week / O month) and are likely to last approximately (El hours / ❑ days) per episode.
(12) My leave is due to a qualifying exigency that involves Rest and Recuperation leave (R & R) of the military
member (leave for this reason is limited to 15 calendar days for each instance of R & R leave).
List the dates of the military member's R &R leave:
From (mm/dd/yyyy) to (mm/dd/yyyy)
PART D: THIRD PARTY INFORMATION
If applicable, please provide information below that may be used by your employer to verify meetings or appointments with
a third party related to the qualifying exigency. Examples of meetings with third parties include: arranging for childcare or
parental care, to attend non -medical counseling, to attend meetings with school, childcare or parental care providers, to
make financial or legal arrangements, to act as the military member's representative before a federal, state, or local agency
for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military
or military service organizations. This information may be used by your employer to verify that the information contained
on this form is accurate.
Individual (e.g., name and title) or Entity / Organization:
Address:
Telephone: ()
Describe purpose of meeting:
Employee
Signature
Fax: ()
E-mail:
Date
(mm/dd/yyyy)
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. §
2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number. The Department of Labor estimates that it will take an average of 15 minutes for respondents
to complete this collection of information, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any
comments regarding this burden estimate or any other aspect of this collection information, including suggestions for
reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room 5-3502,
200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF DEPARTMENT OF LABOR.
RETURN FORM TO THE EMPLOYER.
Page 4 of 4 Form WH-384, Revised June 2020
Designation Notice U.S. Department of Labor
under the Family and Medical Leave Act Wage and Hour Division
WAGE AND HOUR DIVISION
DO NOT SEND TO THE DEPARTMENT OF LABOR.
PROVIDE TO EMPLOYEE.
OMB Control Number: 1235-0003
Expires: 6/30/2023
Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform
the employee of the amount of leave that will be counted against the employee's FMLA leave entitlement. In order to determine whether
leave is covered under the FMLA, the employer may request that the leave be supported by a certification. If the certification is
incomplete or insufficient, the employer must state in writing what additional information is necessary to make the certification complete
and sufficient. While use of this form is optional, a fully completed Form WH-382 provides employees with the information required
by 29 C.F.R. §§ 825.300(d), 825.301, and 825.305(c), which must be provided within five business days of the employer having enough
information to determine whether the leave is for an FMLA-qualifying reason. Information about the FMLA may be found on the WHD
website at www.dol.eov/aeencies/whd/fmla.
SECTION I - EMPLOYER
The employer is responsible in all circumstances for designating leave as FMLA-qualifying and giving notice to the employee. Once an
eligible employee communicates a need to take leave for an FMLA-qualifying reason, an employer may not delay designating such
leave as FMLA leave, and neither the employee nor the employer may decline FMLA protection for that leave.
Date
(mm/dd/yyyy)
From: (Employer) To: (Employee)
On (mm/dd/yyyy) we received your most recent information to support your need for leave due to:
(Select as appropriate)
❑ The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or newly -
placed child
❑ Your own serious health condition
❑ The serious health condition of your spouse, child, or parent
❑ A qualifying exigency arising out of the fact that your spouse, child, or parent is on covered active duty or has been notified
of an impending call or order to covered active duty with the Armed Forces
❑ A serious injury or illness of a covered servicemember where you are the servicemember's spouse, child, parent, or next of
kin (Military Caregiver Leave)
We have reviewed information related to your need for leave under the FMLA along with any supporting documentation
provided and decided that your FMLA leave request is: (Select as appropriate)
❑ Approved. All leave taken for this reason will be designated as FMLA leave. Go to Section III for more information.
❑ Not Approved: (Select as appropriate)
❑ The FMLA does not apply to your leave request.
❑ As of the date the leave is to start, you do not have any FMLA leave available to use.
❑ Other
❑ Additional information is needed to determine if your leave request qualifies as FMLA leave. (Go to Section II for the specific
information needed. If your FMLA leave request is approved and no additional information is needed, go to Section III.)
SECTION II — ADDITIONAL INFORMATION NEEDED
We need additional information to determine whether your leave request qualifies under the FMLA. Once we obtain the additional
information requested, we will inform you within 5 business days if your leave will or will not be designated as FMLA leave and count
towards the amount of FMLA leave you have available. Failure to provide the additional information as requested may result in a
denial of your FMLA leave request.
If you have any questions, please contact: at
(Name of employer FMLA representative) (Contact information)
Incomplete or Insufficient Certification
The certification you have provided is incomplete and/or insufficient to determine whether the FMLA applies to your leave request.
(Select as applicable)
❑ The certification provided is incomplete and we are unable to determine whether the FMLA applies to your leave
request. `Incomplete" means one or more of the applicable entries on the certification have not been completed.
Page 1 of 2 Form WH-382, Revised June 2020
Employee Name:
❑ The certification provided is insufficient to determine whether the FMLA applies to your leave request. Insufficient" means the
information provided is vague, unclear, ambiguous or non -responsive.
Specify the information needed to make the certification complete and/or sufficient:
You must provide the requested information no later than (provide at least 7 calendar days) (mm/dd/yyyy), unless
it is not practicable under the particular circumstances despite your diligent good faith efforts, or your leave may be denied.
Second and Third Opinions
❑ We request that you obtain a (❑ second / ❑ third opinion) medical certification at our expense, and we will provide further
details at a later time. Note: The employee or the employee's family member may be requested to authorize the health care
provider to release information pertaining only to the serious health condition at issue.
SECTION III — FMLA LEAVE APPROVED
As explained in Section I, your FMLA leave request is approved. All leave taken for this reason will be designated as FMLA leave and
will count against the amount of FMLA leave you have available to use in the applicable 12-month period. The FMLA requires that you
notify us as soon as practicable if the dates of scheduled leave change, are extended, or were initially unknown. Based on the information
you have provided to date, we are providing the following information about the amount of time that will be counted against the total
amount of FMLA leave you have available to use in the applicable 12-month period: (Select as appropriate)
❑ Provided there is no change from your anticipated FMLA leave schedule, the following number of hours, days, or weeks
will be counted against your leave entitlement:
❑ Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or weeks that will be
counted against your FMLA entitlement at this time. You have the right to request this information once in a 30-day period (if
leave was taken in the 30-day period).
Please be advised: (check all that apply)
❑ Some or all of your FMLA leave will not be paid. Any unpaid FMLA leave taken will be designated as FMLA leave and
counted against the amount of FMLA leave you have available to use in the applicable 12-month period.
❑ Based on your request, some or all of your available paid leave (e.g., sick, vacation, PTO) will be used during your FMLA
leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of FMLA leave
you have available to use in the applicable 12-month period.
❑ We are requiring you to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA leave.
Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of FMLA leave you
have available to use in the applicable 12-month period.
❑ Other:
(e.g., Short- or long-term disability, workers' compensation, state medical leave law, etc) Any time taken for this reason will
also be designated as FMLA leave and counted against the amount of FMLA leave you have available to use in the applicable
12-month period.
Return -to -work requirements. To be restored to work after taking FMLA leave, you (0 will be / 0 will not be) required to provide a
certification from your health care provider (fitness -for -duty certification) that you are able to resume work. This request for a fitness -
for -duty certification is only with regard to the particular serious health condition that caused your need for FMLA leave. If such
certification is not timely received, your return to work may be delayed until the certification is provided.
A list of the essential functions of your position (0 is / 0 is not) attached. If attached, the fitness -for -duty certification must address
your ability to perform the essential job functions.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
It is mandatory for employers to inform employees in writing whether leave requested under the FMLA has been determined to be covered
under the FMLA. 29 U.S.C. § 2617; 29 C.F.R. § 825.300(d), (e). It is mandatory for employers to retain a copy of this disclosure in their records
for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays
a currently valid OMB control number. The Department of Labor estimates that it will take an average of 10 minutes for respondents to complete
this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other
aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division,
U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF LABOR. EMPLOYEE INFORMATION.
Page 2 of 2 Form WH-382, Revised June 2020
Notice of Eligibility & Rights and Responsibilities
under the Family and Medical Leave Act
DO NOT SEND TO THE DEPARTMENT OF LABOR.
PROVIDE TO EMPLOYEE.
U.S. Department of Labor ^�
HO
Wage and Hour Division
WAGE AND HOUR DIVISION
OMB Control Number: 1235-0003
Expires: 6/30/2023
In general, to be eligible to take leave under the Family and Medical Leave Act (FMLA), an employee must have worked
for an employer for at least 12 months, meet the hours of service requirement in the 12 months preceding the leave, and
work at a site with at least 50 employees within 75 miles. While use of this form is optional, a fully completed Form WH-
381 provides employees with the information required by 29 C.F.R. §§ 825.300(b), (c) which must be provided within five
business days of the employee notifying the employer of the need for FMLA leave. Information about the FMLA may be
found on the WHD website at www.dol.gov/agencies/whd/fmla.
Date
From:
(mm/dd/yyyy)
(Employer) TO:
On (mm/dd/yyyy), we learned that you need leave (beginning on)
for one of the following reasons: (Select as appropriate)
(Employee)
(mm/dd/yyyy)
❑ The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or
newly -placed child
❑ Your own serious health condition
❑ You are needed to care for your family member due to a serious health condition. Your family member is your:
❑ Spouse ❑ Parent ❑ Child under age 18 ❑ Child 18 years or older and incapable of self -
care because of a mental or physical disability
❑ A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of
an impending call or order to covered active duty status. Your family member on covered active duty is your:
❑ Spouse ❑ Parent ❑ Child of any age
❑ You are needed to care for your family member who is a covered servicemember with a serious injury or illness. You
are the servicemember's:
❑ Spouse ❑ Parent ❑ Child ❑ Next of kin
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in a common law
marriage or same -sex marriage. The terms "child" and "parent" include in loco parentis relationships in which a person assumes the
obligations of a parent to a child. An employee may take FMLA leave to care for an individual who assumed the obligations of a parent
to the employee when the employee was a child. An employee may also take FMLA leave to care for a child for whom the employee
has assumed the obligations of a parent. No legal or biological relationship is necessary.
SECTION I — NOTICE OF ELIGIBILITY
This Notice is to inform you that you are:
❑ Eligible for FMLA leave. (See Section II for any Additional Information Needed and Section III for information on your Rights
and Responsibilities.)
❑ Not eligible for FMLA leave because: (Only one reason need be checked)
❑ You have not met the FMLA's 12-month length of service requirement. As of the first date of requested leave,
you will have worked approximately: towards this requirement.
(months)
❑ You have not met the FMLA's 1,250 hours of service requirement. As of the first date of requested leave, you
will have worked approximately: towards this requirement.
(hours of service)
Page 1 of 4 Form WH-381, Revised June 2020
Employee Name:
❑ You are an airline flight crew employee and you have not met the special hours of service eligibility requirements
for airline flight crew employees as of the first date of requested leave (i.e., worked or been paid for at least 60%
of your applicable monthly guarantee, and worked or been paid for at least 504 duty hours.)
❑ You do not work at and/or report to a site with 50 or more employees within 75-miles as of the date of your
request.
If you have any questions, please contact: (Name of employer representative)
at
SECTION II — ADDITIONAL INFORMATION NEEDED
(Contact information).
As explained in Section I, you meet the eligibility requirements for taking FMLA leave. Please review the information
below to determine if additional information is needed in order for us to determine whether your absence qualifies as FMLA
leave. Once we obtain any additional information specified below we will inform you, within 5 business days, whether
your leave will be designated as FMLA leave and count towards the FMLA leave you have available. If complete and
sufficient information is not provided in a timely manner, your leave may be denied.
(Select as appropriate)
❑ No additional information requested. If no additional information requested, go to Section 111.
❑ We request that the leave be supported by a certification, as identified below.
O Health Care Provider for the Employee O Health Care Provider for the Employee's Family Member
0 Qualifying Exigency 0 Serious Illness or Injury (Military Caregiver Leave)
Selected certification form is 0 attached / 0 not attached.
If requested, medical certification must be returned by (mm/dd/yyyy) (Must allow at least 15
calendar days from the date the employer requested the employee to provide certification, unless it is not feasible despite the employee's
diligent, good faith efforts)
❑ We request that you provide reasonable documentation or a statement to establish the relationship between you and
your family member, including in loco parentis relationships (as explained on page one). The information requested
must be returned to us by (mm/dd/yyyy). You may choose to provide a simple statement of the
relationship or provide documentation such as a child's birth certificate, a court document, or documents regarding
foster care or adoption -related activities. Official documents submitted for this purpose will be returned to you after
examination.
❑ Other information needed (e.g. documentation for military family leave):
The information requested must be returned to us by
(mm/dd/yyyy).
If you have any questions, please contact: (Name of employer representative)
at (Contact information).
SECTION III — NOTICE OF RIGHTS AND RESPONSIBILITIES
Part A: FMLA Leave Entitlement
You have a right under the FMLA to take unpaid, job -protected FMLA leave in a 12-month period for certain family and
medical reasons, including up to 12 weeks of unpaid leave in a 12-month period for the birth of a child or placement of a
child for adoption or foster care, for leave related to your own or a family member's serious health condition, or for certain
qualifying exigencies related to the deployment of a military member to covered active duty. You also have a right
Page 2 of 4 Form WH-381, Revised June 2020
Employee Name:
under the FMLA to take up to 26 weeks of unpaid, job -protected FMLA leave in a single 12-month period to care for a
covered servicemember with a serious injury or illness (Military Caregiver Leave).
The 12-month period for FMLA leave is calculated as: (Select as appropriate)
❑ The calendar year (January 1st -December 31")
❑ A fixed leave year based on
(e.g., a fiscal year beginning on July 1 and ending on June 30)
❑ The 12-month period measured forward from the date of your first FMLA leave usage.
❑ A "rolling" 12-month period measured backward from the date of any FMLA leave usage. (Each time an employee
takes FMLA leave, the remaining leave is the balance of the 12 weeks not used during the 12 months immediately before
the FMLA leave is to start.)
If applicable, the single 12-month period for Military Caregiver Leave started on (mm/dd/yyyy).
You (❑ are / ❑ are not) considered a key employee as defined under the FMLA. Your FMLA leave cannot be denied for
this reason; however, we may not restore you to employment following FMLA leave if such restoration will cause
substantial and grievous economic injury to us.
We (❑ have / ❑ have not) determined that restoring you to employment at the conclusion of FMLA leave will cause
substantial and grievous economic harm to us. Additional information will be provided separately concerning your status
as key employee and restoration.
Part B: Substitution of Paid Leave — When Paid Leave is Used at the Same Time as FMLA Leave
You have a right under the FMLA to request that your accrued paid leave be substituted for your FMLA leave. This means
that you can request that your accrued paid leave run concurrently with some or all of your unpaid FMLA leave, provided
you meet any applicable requirements of our leave policy. Concurrent leave use means the absence will count against both
the designated paid leave and unpaid FMLA leave at the same time. If you do not meet the requirements for taking paid
leave, you remain entitled to take available unpaid FMLA leave in the applicable 12-month period. Even if you do not
request it, the FMLA allows us to require you to use your available sick, vacation, or other paid leave during your FMLA
absence.
(Check all that apply)
❑ Some or all of your FMLA leave will not be paid. Any unpaid FMLA leave taken will be designated as FMLA
leave and counted against the amount of FMLA leave you have available to use in the applicable 12-month period.
❑ You have requested to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA
leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of
FMLA leave you have available to use in the applicable 12-month period.
❑ We are requiring you to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA
leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of
FMLA leave you have available to use in the applicable 12-month period.
❑ Other: (e.g., short- or long-term disability, workers' compensation, state medical leave law, etc.)
Any time taken for this reason will also be designated as FMLA leave and counted against the amount of
FMLA leave you have available to use in the applicable 12-month period.
The applicable conditions for use of paid leave include:
For more information about conditions applicable to sick/vacation/other paid leave usage please refer to
available at:
Page 3 of Form WH-381, Revised June 2020
Employee Name:
Part C: Maintain Health Benefits
Your health benefits must be maintained during any period of FMLA leave under the same conditions as if you continued
to work. During any paid portion of FMLA leave, your share of any premiums will be paid by the method normally used
during any paid leave. During any unpaid portion of FMLA leave, you must continue to make any normal contributions to
the cost of the health insurance premiums. To make arrangements to continue to make your share of the premium payments
on your health insurance while you are on any unpaid FMLA leave, contact at
You have a minimum grace period of (❑ 30-days or ❑ indicate longer period, if applicable) in which to
make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify
you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share
of the premiums during FMLA leave, and recover these payments from you upon your return to work.
You may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA
leave if you do not return to work following unpaid FMLA leave for a reason other than: the continuation, recurrence, or
onset of your or your family member's serious health condition which would entitle you to FMLA leave; or the continuation,
recurrence, or onset of a covered servicemember' s serious injury or illness which would entitle you to FMLA leave; or
other circumstances beyond your control.
Part D: Other Emnlovee Benefits
Upon your return from FMLA leave, your other employee benefits, such as pensions or life insurance, must be resumed in
the same manner and at the same levels as provided when your FMLA leave began. To make arrangements to continue
your employee benefits while you are on FMLA leave, contact
at
Part E: Return -to -Work Requirements
You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment
on your return from FMLA-protected leave. An equivalent position is one that is virtually identical to your former position
in terms of pay, benefits, and working conditions. At the end of your FMLA leave, all benefits must also be resumed in the
same manner and at the same level provided when the leave began. You do not have return -to -work rights under the FMLA
if you need leave beyond the amount of FMLA leave you have available to use.
Part F: Other Requirements While on FMLA Leave
While on leave you (❑ will be / ❑ will not be) required to fiarnish us with periodic reports of your status and intent to
return to work every
(Indicate interval of periodic reports, as appropriate for the FMLA leave situation).
If the circumstances of your leave change and you are able to return to work earlier than expected,
you will be required to notify us at least two workdays prior to the date you intend to report for work.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
It is mandatory for employers to provide employees with notice of their eligibility for FMLA protection and their rights and
responsibilities. 29 U.S.C. § 2617; 29 C.F.R. § 825.300(b), (c). It is mandatory for employers to retain a copy of this disclosure in their
records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 10 minutes
for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send
them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF LABOR. EMPLOYEE INFORMATION.
Page 4 of 4 Form WH-381, Revised June 2020
Certification of Health Care Provider for U.S. Department of Labor 00,
Family Member's Serious Health Condition Wage Hour Division MOW N a
under the Family and Medical Leave Act WAGE AND HOUR DIVISION
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR OMB Control Number: 1235-0003
RETURN TO THE PATIENT. Expires: 6/30/2023
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave to care for a
family member with a serious health condition to submit a medical certification issued by the family member's health care provider. 29
U.S.C. §§ 2613, 2614(c)(3); 29 C.F.R. § 825.305. The employer must give the employee at least 15 calendar days to provide the
certification. If the employee fails to provide complete and sufficient medical certification, his or her FMLA leave request may be
denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the WHD website at www.dol.2ov/a2encies/whd/fmla.
SECTION I - EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, this form asks the health care provider
for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R. § 825.306. You may not
ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308.
Additionally, you may not request a certification for FMLA leave to bond with a healthy newborn child or a child placed for adoption
or foster care.
Employers must generally maintain records and documents relating to medical information, medical certifications, recertifications, or
medical histories of employees or employees' family members created for FMLA purposes as confidential medical records in separate
files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act
applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
(1) Employee name:
(2) Employer name:
First Middle Last
Date: (mm/dd/yyyy)
(List date certification requested)
(3) The medical certification must be returned by (mm/dd/yyyy)
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee's diligent, good faith efforts)
W SECTION II - EMPLOYEE —MMME
Please complete and sign Section II before providing this form to your family member or your family member's health care provider.
The FMLA allows an employer to require that you submit a timely, complete, and sufficient medical certification to support a request
for FMLA leave due to the serious health condition of your family member. If requested by your employer, your response is required
to obtain or retain the benefit of the FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). You are responsible for making sure the
medical certification is provided to your employer within the time frame requested, which must be at least 15 calendar days. 29
C.F.R. §§ 825.305-825.306. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA
leave request. 29 C.F.R. § 825.313.
(1) Name of the family member for whom you will provide care:
(2) Select the relationship of the family member to you. The family member is your:
❑ Spouse ❑ Parent ❑ Child, under age 18
❑ Child, age 18 or older and incapable of self -care because of a mental or physical disability
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in a
common law marriage or same -sex marriage. The terms "child" and "parent" include in loco parentis relationships in which
a person assumes the obligations of a parent to a child. An employee may take FMLA leave to care for an individual who
assumed the obligations of a parent to the employee when the employee was a child. An employee may also take FMLA
leave to care for a child for whom the employee has assumed the obligations of a parent. No legal or biological relationship
is necessary.
Page 1 of 4 Form WH-380-F, Revised June 2020
Employee Name:
(3) Briefly describe the care you will provide to your family member: (Check all that apply)
❑ Assistance with basic medical, hygienic, nutritional, or safety needs ❑ Transportation
❑ Physical Care ❑ Psychological Comfort ❑ Other:
(4) Give your best estimate of the amount of leave needed to provide the care described:
(5) If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced schedule
you are able to work. From
Employee
Signature
(hours per day)
(mm/dd/yyyy) to
(days per week).
Date
(mm/dd/yyyy), I am able to work
SECTION III - HEALTH CARE PROVIDER
(mm/dd/yyyy)
EPW
Please provide your contact information, complete all relevant parts of this Section, and sign the form below. A family member of your
patient has requested leave under the FMLA to care for your patient. The FMLA allows an employer to require that the employee submit
a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a family member with a serious
health condition. For FMLA purposes, a "serious health condition" means an illness, injury, impairment, or physical or mental condition
that involves inpatient care or continuing treatment by a health care provider. For more information about the definitions of a serious
health condition under the FMLA, see the chart at the end of the form.
You also may, but are not required to, provide other appropriate medical facts including symptoms, diagnosis, or any regimen of
continuing treatment such as the use of specialized equipment. Please note that some state or local laws may not allow disclosure of
private medical information about the patient's serious health condition, such as providing the diagnosis and/or course of treatment.
Health Care Provider's name: (Print)
Health Care Provider's business address:
Type of practice / Medical specialty:
Telephone: ( Fax: ( ) E-mail:
PART A: Medical Information
Limit your response to the medical condition for which the employee is seeking FMLA leave. Your answers should be your
best estimate based upon your medical knowledge, experience, and examination of the patient. After completing Part A, complete
Part B to provide information about the amount of leave needed. Note: For FMLA purposes, "incapacity" means the inability to
work, attend school, or perform regular daily activities due to the condition, treatment of the condition, or recovery from the condition.
Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e),
or the manifestation of disease or disorder in the employee's family members, 29 C.F.R. § 1635.3(b).
(1) Patient's Name:
(2) State the approximate date the condition started or will start:
(3) Provide your best estimate of how long the condition lasted or will last:
(mm/dd/yyyy)
(4) For FMLA to apply, care of the patient must be medically necessary. Briefly describe the type of care needed by the patient
(e.g., assistance with basic medical, hygienic, nutritional, safety, transportation needs, physical care, or psychological comfort).
Page 2 of 4 Form WH-380-F, Revised June 2020
Employee Name:
(5) Check the box(es) for the questions below, as applicable. For all box(es) checked, the amount of leave needed must be
provided in Part B.
❑ Inpatient Care: The patient (❑ has been / ❑ is expected to be) admitted for an overnight stay in a hospital,
hospice, or residential medical care facility on the following date(s):
❑ Incauacity ulus Treatment: (e.g. outpatient surgery, strep throat)
Due to the condition, the patient (❑ has been / ❑ is expected to be) incapacitated for more than three
consecutive, full calendar days from (mm/dd/yyyy) to (mm/dd/yyyy).
The patient (❑ was / ❑ will be) seen on the following date(s):
The condition (❑ has / ❑ has not) also resulted in a course of continuing treatment under the supervision of a
health care provider (e.g. prescription medication (other than over-the-counter) or therapy requiring special equipment)
❑ Pregnancv: The condition is pregnancy. List the expected delivery date: (mm/dd/yyyy).
❑ Chronic Conditions: (e.g. asthma, migraine headaches) Due to the condition, it is medically necessary for the patient
to have treatment visits at least twice per year.
❑ Permanent or Long Term Conditions: (e.g. Alzheimer's, terminal stages of cancer) Due to the condition, incapacity
is permanent or long term and requires the continuing supervision of a health care provider (even if active
treatment is not being provided).
❑ Conditions requiring Multiple Treatments: (e.g. chemotherapy treatments, restorative surgery) Due to the condition,
it is medically necessary for the patient to receive multiple treatments.
❑ None of the above: If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy)
no additional information is needed. Go to page 4 to sign and date the form.
(6) If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks
FMLA leave. (e.g., use of nebulizer, dialysis)
PART B: Amount of Leave Needed
For the medical condition(s) checked in Part A, complete all that apply. Several questions seek a response as to the frequency or duration
of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and
examination of the patient. Be as specific as you can; terms such as "lifetime," "unknown," or "indeterminate" may not be sufficient to
determine if the benefits and protections of the FMLA apply.
(7) Due to the condition, the patient (❑ had / ❑ will have) planned medical treatment(s) (scheduled medical visits) (e.g.
psychotherapy, prenatal appointments) on the following date(s):
(8) Due to the condition, the patient (❑ was / ❑ will be) referred to other health care provider(s) for evaluation or
treatment(s).
State the nature of such treatments: (e.g. cardiologist, physical therapy)
Provide your best estimate of the beginning date (mm/dd/yyyy) and end date
(mm/dd/yyyy) for the treatment(s).
Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery
(e.g. 3 days/week)
Page 3 of 4 Form WH-380-F, Revised June 2020
Employee Name:
(9) Due to the condition, the patient (❑ was / ❑ will be) incapacitated for a continuous period of time, including any time
for treatment(s) and/or recovery.
Provide your best estimate of the beginning date:
(mm/dd/yyyy) for the period of incapacity.
(mm/dd/yyyy) and end date
(10) Due to the condition it, (❑ was / ❑ is / ❑ will be) medically necessary for the employee to be absent from work to
provide care for the patient on an intermittent basis (periodically), including for any episodes of incapacity i.e., episodic
flare-ups. Provide your best estimate of how often (frequency) and how long (duration) the episodes of incapacity
will likely last.
Over the next 6 months, episodes of incapacity are estimated to occur
(0 day / 0 week / 0 month) and are likely to last approximately
episode.
Signature of
Health Care Provider
times per
(0 hours / 0 days) per
Date (mm/dd/yyyy)
Definitions of a Serious Health Condition (See 29 C.F.R. §§ 825.113-.115)
Inpatient Care
• An overnight stay in a hospital, hospice, or residential medical care facility.
• Inpatient care includes any period of incapacity or any subsequent treatment in connection with the overnight stay.
Continuing Treatment by a Health Care Provider (any one or more of the following)
Incapacity Plus Treatment: A period of incapacity of more than three consecutive, full calendar days, and any subsequent treatment
or period of incapacity relating to the same condition, that also involves either:
o Two or more in -person visits to a health care provider for treatment within 30 days of the first day of incapacity unless
extenuating circumstances exist. The first visit must be within seven days of the first day of incapacity; or,
o At least one in -person visit to a health care provider for treatment within seven days of the first day of incapacity, which
results in a regimen of continuing treatment under the supervision of the health care provider. For example, the health
provider might prescribe a course of prescription medication or therapy requiring special equipment.
PreLynancv: Any period of incapacity due to pregnancy or for prenatal care.
Chronic Conditions: Any period of incapacity due to or treatment for a chronic serious health condition, such as diabetes, asthma,
migraine headaches. A chronic serious health condition is one which requires visits to a health care provider (or nurse supervised by
the provider) at least twice a year and recurs over an extended period of time. A chronic condition may cause episodic rather than a
continuing period of incapacity.
Permanent or Long-term Conditions: A period of incapacity which is permanent or long-term due to a condition for which
treatment may not be effective, but which requires the continuing supervision of a health care provider, such as Alzheimer's disease
or the terminal stages of cancer.
Conditions Reauirina Multiple Treatments: Restorative surgery after an accident or other injury; or, a condition that would likely
result in a period of incapacity of more than three consecutive, full calendar days if the patient did not receive the treatment.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616;
29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
The Department of Labor estimates that it will take an average of 15 minutes for respondents to complete this collection of information, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for
reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue,
N.W., Washington, D.C. 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
Page 4 of 4 Form W11-380-F, Revised June 2020
Certification of Health Care Provider for
Employee's Serious Health Condition
under the Family and Medical Leave Act
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR
RETURN TO THE PATIENT.
U.S. Department of Labor 51MEND
Wage and Hour Division
WAGE AND HOUR DIVISION
OMB Control Number: 1235-0003
Expires: 6/30/2023
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections
because of a need for leave due to a serious health condition to submit a medical certification issued by the employee's
health care provider. 29 U.S.C. §§ 2613, 2614(c)(3); 29 C.F.R. § 825.305. The employer must give the employee at least
15 calendar days to provide the certification. If the employee fails to provide complete and sufficient medical certification,
his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the
WHD website at www.dol.2ov/a2encies/whd/fmla.
SECTION I — EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, this form asks the health
care provider for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R.
§ 825.306. You may not ask the employee to provide more information than allowed under the FMLA regulations,
29 C.F.R. §§ 825.306-825.308. Additionally, you may not request a certification for FMLA leave to bond with a healthy
newborn child or a child placed for adoption or foster care.
Employers must generally maintain records and documents relating to medical information, medical certifications,
recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate
files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with
Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act
applies.
(1) Employee name:
First Middle Last
(2) Employer name: Date: (mm/dd/yyyy)
(List date certification requested)
(3) The medical certification must be returned by (mm/dd/yyyy)
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee's diligent, good faith efforts)
(4) Employee's job title: Job description (0 is / 0 is not) attached.
Employee's regular work schedule:
Statement of the employee's essential job functions:
(The essential functions of the employee's position are determined with reference to the position the employee held at the time the employee
notified the employer of the need for leave or the leave started, whichever is earlier.)
SECTION II - HEALTH CARE PROVIDER
Please provide your contact information, complete all relevant parts of this Section, and sign the form. Your patient has
requested leave under the FMLA. The FMLA allows an employer to require that the employee submit a timely, complete,
and sufficient medical certification to support a request for FMLA leave due to the serious health condition of the employee.
For FMLA purposes, a "serious health condition" means an illness, injury, impairment, or physical or mental condition that
involves inpatient care or continuing treatment by a health care provider. For more information about the definitions of a
serious health condition under the FMLA, see the chart on page 4.
You may, but are not required to, provide other appropriate medical facts including symptoms, diagnosis, or any regimen
of continuing treatment such as the use of specialized equipment. Please note that some state or local laws may not allow
disclosure of private medical information about the patient's serious health condition, such as providing the diagnosis and/or
course of treatment.
Page 1 of 4 Form WH-380-E, Revised June 2020
Employee Name:
Health Care Provider's name: (Print)
Health Care Provider's business address:
Type of practice / Medical specialty:
Telephone: (_) Fax: ( ) E-mail:
PART A: Medical Information
Limit your response to the medical condition(s) for which the employee is seeking FMLA leave. Your answers should be
your best estimate based upon your medical knowledge, experience, and examination of the patient. After completing
Part A, complete Part B to provide information about the amount of leave needed. Note: For FMLA purposes,
"incapacity" means the inability to work, attend school, or perform regular daily activities due to the condition, treatment
of the condition, or recovery from the condition. Do not provide information about genetic tests, as defined in 29 C.F.R. §
1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee's
family members, 29 C.F.R. § 1635.3(b).
(1) State the approximate date the condition started or will start:
(2) Provide your best estimate of how long the condition lasted or will last:
(mm/dd/yyyy)
(3) Check the box(es) for the questions below, as applicable. For all box(es) checked, the amount of leave needed must be
provided in Part B.
❑ Inpatient Care: The patient (❑ has been / ❑ is expected to be) admitted for an overnight stay in a hospital,
hospice, or residential medical care facility on the following date(s):
❑ Incapacity plus Treatment: (e.g. outpatient surgery, strep throat)
Due to the condition, the patient (❑ has been / ❑ is expected to be) incapacitated for more than three
consecutive, full calendar days from (mm/dd/yyyy) to (mm/dd/yyyy).
The patient (❑ was / ❑ will be) seen on the following date(s):
The condition (❑ has / ❑ has not) also resulted in a course of continuing treatment under the supervision of a
health care provider (e.g. prescription medication (other than over-the-counter) or therapy requiring special equipment)
❑ Pregnancv: The condition is pregnancy. List the expected delivery date: (mm/dd/yyyy).
❑ Chronic Conditions: (e.g. asthma, migraine headaches) Due to the condition, it is medically necessary for the patient
to have treatment visits at least twice per year.
❑ Permanent or Long Term Conditions: (e.g. Alzheimer's, terminal stages of cancer) Due to the condition, incapacity
is permanent or long term and requires the continuing supervision of a health care provider (even if active
treatment is not being provided).
❑ Conditions requiring Multiple Treatments: (e.g. chemotherapy treatments, restorative surgery) Due to the condition,
it is medically necessary for the patient to receive multiple treatments.
❑ None of the above: If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy)
no additional information is needed. Go to page 4 to sign and date the form.
Page 2 of Form WH-380-E, Revised June 2020
Employee Name:
(4) If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks
FMLA leave. (e.g., use of nehulizer, dialysis)
PART B: Amount of Leave Needed
For the medical condition(s) checked in Part A, complete all that apply. Several questions seek a response as to the frequency
or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge,
experience, and examination of the patient. Be as specific as you can; terms such as "lifetime," "unknown," or "indeterminate"
may not be sufficient to determine FMLA coverage.
(5) Due to the condition, the patient (❑ had / ❑ will have) planned medical treatment(s) (scheduled medical visits)
(e.g. psychotherapy, prenatal appointments) on the following date(s):
(6) Due to the condition, the patient (❑ was / ❑ will be) referred to other health care provider(s) for evaluation or
treatment(s).
State the nature of such treatments: (e.g. cardiologist, physical therapy)
Provide your best estimate of the beginning date
(mm/dd/yyyy) for the treatment(s).
(mm/dd/yyyy) and end date
Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery (e.g. 3 days/week)
(7) Due to the condition, it is medically necessary for the employee to work a reduced schedule.
Provide your best estimate of the reduced schedule the employee is able to work. From
(mm/dd/yyyy) to (mm/dd/yyyy) the employee is able to work: (e.g., 5 hours/day, up to 25 hours a week)
(8) Due to the condition, the patient (❑ was / ❑ will be) incapacitated for a continuous period of time, including any
time for treatment(s) and/or recovery.
Provide your best estimate of the beginning date
(mm/dd/yyyy) for the period of incapacity.
(mm/dd/yyyy) and end date
(9) Due to the condition, it (❑ was / ❑ is / ❑ will be) medically necessary for the employee to be absent from work on
an intermittent basis (periodically), including for any episodes of incapacity i.e., episodic flare-ups. Provide your
best estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.
Over the next 6 months, episodes of incapacity are estimated to occur times per
(M day / 0 week / 0 month) and are likely to last approximately (❑ hours / 0 days) per episode.
Page 3 of Form WH-380-E, Revised June 2020
Employee Name:
PART C: Essential Job Functions
If provided, the information in Section I question #4 may be used to answer this question. If the employer fails to provide a
statement of the employee's essential functions or a job description, answer these questions based upon the employee's own
description of the essential job functions. An employee who must be absent from work to receive medical treatment(s), such
as scheduled medical visits, for a serious health condition is considered to be not able to perform the essential job functions
of the position during the absence for treatment(s).
(10) Due to the condition, the employee (❑ was not able / ❑ is not able / ❑ will not be able) to perform one or more
of the essential job function(s). Identify at least one essential job function the employee is not able to perform:
Signature of
Health Care Provider Date (mm/dd/yyyy)
Definitions of a Serious Health Condition (see 29 C.P.R. §§ 825.113-115)
Inpatient Care
• An overnight stay in a hospital, hospice, or residential medical care facility.
• Inpatient care includes any period of incapacity or any subsequent treatment in connection with the overnight stay.
Continuing Treatment by a Health Care Provider (any one or more of the following)
Incapacity Plus Treatment: A period of incapacity of more than three consecutive, full calendar days, and any subsequent treatment
or period of incapacity relating to the same condition, that also involves either:
o Two or more in -person visits to a health care provider for treatment within 30 days of the first day of incapacity unless
extenuating circumstances exist. The first visit must be within seven days of the first day of incapacity; or,
o At least one in -person visit to a health care provider for treatment within seven days of the first day of incapacity, which
results in a regimen of continuing treatment under the supervision of the health care provider. For example, the health
provider might prescribe a course of prescription medication or therapy requiring special equipment.
Preenancv: Any period of incapacity due to pregnancy or for prenatal care.
Chronic Conditions: Any period of incapacity due to or treatment for a chronic serious health condition, such as diabetes, asthma,
migraine headaches. A chronic serious health condition is one which requires visits to a health care provider (or nurse supervised by
the provider) at least twice a year and recurs over an extended period of time. A chronic condition may cause episodic rather than a
continuing period of incapacity.
Permanent or Long-term Conditions: A period of incapacity which is permanent or long-term due to a condition for which
treatment may not be effective, but which requires the continuing supervision of a health care provider, such as Alzheimer's disease
or the terminal stages of cancer.
Conditions Reauiring Multiple Treatments: Restorative surgery after an accident or other injury; or, a condition that would likely
result in a period of incapacity of more than three consecutive, full calendar days if the patient did not receive the treatment.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons
are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates
that it will take an average of 15 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the
Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.
Page 4 of 4 Form WH-380-E, Revised June 2020