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

Fill out Form WH-380-F online

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

Form WH-380-F is the Department of Labor's optional form for certifying that an employee needs FMLA leave to care for a spouse, parent or child with a serious health condition. The employee fills in their part, and the family member's health care provider describes the condition and estimates the leave or care needed. The completed form goes to the employer, not to the Department of Labor.

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

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Edition: Revised June 2020
Pages: 4
Fillable fields: 85
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-F

Employees asking for FMLA leave to care for a spouse, parent or child with a serious health condition
Employers that ask for a medical certification to support that leave
The health care provider of the family member who needs care

Before you start

The date your employer asked for the certification and the date it must be returned
Your family member's full name and how they are related to you
A short description of the care you will provide, such as transportation or physical care
Your best estimate of how much leave you need, and the dates and hours of any reduced work schedule
A way to reach your family member's health care provider, who completes Section III

How to fill out Form WH-380-F

Section I – Employer
Either you or your employer can fill in Section I. Item 1 is the employee's first, middle and last name. Item 2 is the employer's name and the date the certification was requested. Item 3 is the date the certification must be returned, which must be at least 15 calendar days after the request unless that is not feasible despite the employee's diligent, good faith efforts.
Section II – Employee, items 1 to 3
Enter the name of the family member you will care for (item 1) and check the relationship (item 2): spouse, parent, child under age 18, or child age 18 or older who is incapable of self-care because of a mental or physical disability. The form notes that “child” and “parent” include someone who took on the role of a parent, with no legal or biological relationship needed. In item 3, check each type of care you will give: assistance with basic medical, hygienic, nutritional or safety needs, transportation, physical care, psychological comfort, or other.
Section II – Employee, items 4 and 5, and your signature
Item 4 asks for your best estimate of the leave you need to provide the care. If you need a reduced work schedule, item 5 asks for the dates and the hours per day and days per week you are able to work. Sign and date Section II before you give the form to your family member or their health care provider. Pages 2, 3 and 4 each have an Employee Name line at the top.
Section III – Health care provider's contact details
The provider prints their name, business address, type of practice or medical specialty, telephone, fax and email. The provider may, but does not have to, give other medical facts such as symptoms or a diagnosis.
Part A – Medical Information (items 1 to 6)
The provider limits the answers to the condition for which the employee is asking for leave. Item 1 is the patient's name, item 2 the approximate date the condition started or will start, and item 3 how long it lasted or will last. Item 4 describes the care the patient needs, which must be medically necessary. Item 5 has checkboxes for inpatient care, incapacity plus treatment, pregnancy, chronic conditions, permanent or long-term conditions, conditions requiring multiple treatments, and none of the above; if none apply, the provider goes to page 4 to sign. Item 6 is for other appropriate medical facts, if needed.
Part B – Amount of Leave Needed (items 7 to 10)
For each condition checked in Part A, the provider gives estimates: dates of planned treatments (item 7), referrals to other providers with the type of treatment, start and end dates and duration (item 8), the start and end dates of a continuous period of incapacity (item 9), and, for intermittent leave, how often episodes will occur over the next 6 months and how long each will last (item 10).
Provider signature and date
The provider signs and dates the form on page 4. The same page has a chart of the FMLA definitions of a serious health condition, which match the checkboxes in Part A, item 5.

After you fill it out

The health care provider returns the completed form to the patient, not to the Department of Labor. The employee then gives it to the employer by the date in Section I, item 3; the employee or family member may also authorize the provider to send it to the employer directly. The employer cannot refuse a fax or copy of the certification, and generally must keep it as a confidential medical record, separate from personnel files.

Signing: The employee signs and dates Section II, and the health care provider signs and dates the end of Section III on page 4. The Department of Labor's pages do not say whether an electronic signature is accepted, so follow your employer's instructions, or print the form and sign it in ink.

Watch out for

Do not send the completed form to the Department of Labor. It goes back to the patient, and the employee gives it to the employer. The Department says sending it there may delay the employee's protected FMLA leave.
Estimates such as “lifetime,” “unknown” or “indeterminate” may not be enough for the employer to decide whether FMLA protections apply. The form asks the provider to be as specific as possible.
The provider should not include information about genetic tests, genetic services, or diseases or disorders in the employee's family members.
An employer may not use this form to ask for more information than the FMLA regulations allow, or to ask for a certification for leave to bond with a healthy newborn or a child placed for adoption or foster care.

Questions about Form WH-380-F

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

No. The form is optional. An employer must accept a complete and sufficient certification in any format, such as a communication on the health care provider's letterhead.

How long do I have to return the certification?

Your employer must give you at least 15 calendar days from the date it asked for the certification. If you make diligent, good faith efforts and still cannot meet the deadline, you are entitled to more time.

Does the health care provider have to give a diagnosis?

No. The certification must state appropriate medical facts about the condition, but the provider is not required to give a diagnosis. Some state or local laws may not allow the diagnosis to be disclosed.

What happens if my employer says the certification is incomplete?

If your employer gives you a written notice that the certification is incomplete or insufficient and says what more is needed, you must provide that information within seven calendar days in most circumstances.

Who pays for the certification?

The employee pays for the certification or recertification. If the employer asks for a second or third opinion, the employer pays for it, including reasonable travel expenses for the employee or family member.