U.S. Department of Labor, Wage and Hour Division

Fill out Form WH-380-E online

Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act

Form WH-380-E is an optional Department of Labor form that an employer can use to ask for medical certification when an employee requests FMLA leave for their own serious health condition. The employee or the employer fills in Section I, and the employee's health care provider completes and signs Section II. The finished form goes back to the patient, who gives it to the employer.

Fill out Form WH-380-E Blank form from the Department of Labor

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Edition: Revised June 2020
Pages: 4
Fillable fields: 77
Checked against the Department of Labor: November 8, 2026

GuruPDF is not affiliated with the U.S. Department of Labor, Wage and Hour Division. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses Form WH-380-E

Employees asking for FMLA leave because of their own serious health condition
Employers that ask for medical certification to support that leave
Health care providers who certify the condition and the leave needed
HR staff or leave administrators who review the certification

Before you start

The employee's first, middle and last name, job title and regular work schedule
The employer's name and the date the certification was requested
The date the certification must be returned (at least 15 calendar days after the request)
A job description or a statement of the employee's essential job functions, if the employer provides one
The health care provider's name, business address, type of practice or specialty, phone, fax and email
For the provider: when the condition started, treatment and visit dates, and the time off work expected

How to fill out Form WH-380-E

Section I, items (1) to (3): employee, employer and due date
Either the employee or the employer fills in Section I. Enter the employee's first, middle and last name in item (1), the employer's name and the date certification was requested in item (2), and the date the certification must be returned in item (3). That date must allow at least 15 calendar days from the date requested.
Section I, item (4): the job
Give the employee's job title and mark whether a job description is or is not attached. Then describe the employee's regular work schedule and essential job functions. The essential functions are those of the position the employee held when they told the employer about the need for leave or when the leave started, whichever came first.
Section II: health care provider details
The health care provider prints their name, business address, type of practice or medical specialty, telephone, fax and email. The employee's name also goes at the top of pages 2, 3 and 4.
Part A, items (1) to (4): medical information
The provider gives the approximate date the condition started or will start (1) and a best estimate of how long it lasted or will last (2). In item (3) the provider checks the boxes that apply: inpatient care, incapacity plus treatment, pregnancy, chronic conditions, permanent or long term conditions, or conditions requiring multiple treatments. If none of these apply, the provider checks "None of the above", no more information is needed, and the provider goes to page 4 to sign and date. Item (4) is for other appropriate medical facts, if needed.
Part B, items (5) to (9): amount of leave needed
For each condition checked in Part A, the provider completes the items that apply: planned treatment dates (5), referrals to other health care providers (6), a reduced work schedule (7), a continuous period of incapacity (8), and intermittent absences (9), with how often episodes may occur over the next 6 months and how long each may last. Terms such as "lifetime", "unknown" or "indeterminate" may not be enough.
Part C, item (10): essential job functions, then sign
The provider marks whether the employee was not able, is not able, or will not be able to perform one or more essential job functions, and names at least one of them. If the employer gave no job description or statement of essential functions, the provider answers based on the employee's own description of those functions. The provider then signs and dates the form on page 4.

After you fill it out

Do not send the completed form to the Department of Labor. The health care provider returns it to the patient, and the employee gives it to the employer by the date in Section I, item (3); the employee may also authorize the provider to send it to the employer directly. An employer cannot refuse a fax or copy of the certification. If the employer finds it incomplete or insufficient, it must say in writing what is missing and allow at least seven calendar days to fix it, unless that is not practicable despite the employee's diligent, good faith efforts.

Signing: Only the health care provider signs and dates the form, on page 4. The form and DOL's pages do not say whether an electronic signature is accepted, so if in doubt, print the form and have the provider sign it in ink.

Watch out for

Do not send the completed form to the Department of Labor. DOL says sending it there may delay the employee's protected leave; it goes back to the patient instead.
This form is for the employee's own condition. For leave to care for a family member, DOL's matching form is WH-380-F.
An employer may not ask for more information than the FMLA regulations allow, and may not ask for certification for leave to bond with a healthy newborn or a child placed for adoption or foster care.
The provider should not include information about genetic tests, genetic services, or disease or disorder in the employee's family members.

Questions about Form WH-380-E

Do I have to use Form WH-380-E?

No. It is an optional DOL form, and employers may use their own forms if they ask only for the same basic information. A certification can be in any format, such as on the provider's letterhead, and employers must accept one that is complete and sufficient.

How long do I have to return the certification?

The employer must give you at least 15 calendar days from its request. If you cannot meet the deadline despite diligent, good faith efforts, you are entitled to more time, and the employer may also allow longer.

Does the health care provider have to give a diagnosis?

No. The provider may give a diagnosis but is not required to. The certification must state appropriate medical facts showing the need for leave, and some state or local laws limit what medical information can be shared.

Who pays for the certification?

The employee pays for the certification and any recertification. If the employer asks for a second or third opinion, the employer pays for it.

What does the expiration date at the top of the form mean?

It relates to the form's approval by the Office of Management and Budget. DOL says the content of its optional FMLA forms still applies after that date passes.