U.S. Department of Labor, Wage and Hour Division Edition Revised June 2020 (OMB 1235-0003, expires 8/31/2029) 4 pages

Form WH-380-F (2020) — Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act

The optional FMLA medical certification an employer may ask for when an employee needs leave to care for a spouse, parent or child with a serious health condition. The employer (or employee) fills Section I, the employee fills and signs Section II, and the family member's health care provider completes Section III and signs. It goes back to the employer, never to the Department of Labor.

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Form WH-380-F · Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act
The official U.S. Department of Labor, Wage and Hour Division form, edition Revised June 2020 (OMB 1235-0003, expires 8/31/2029) — blank
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Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 1 of 4
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Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 2 of 4
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Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 3 of 4
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Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 4 of 4
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Fill this form online Blank PDF from U.S. Department of Labor, Wage and Hour Division

What is Form WH-380-F?

The optional FMLA medical certification an employer may ask for when an employee needs leave to care for a spouse, parent or child with a serious health condition. The employer (or employee) fills Section I, the employee fills and signs Section II, and the family member's health care provider completes Section III and signs. It goes back to the employer, never to the Department of Labor.

What’s on Form WH-380-F

The 2020 edition has 4 pages. FileIt asks for it in 5 parts, and it is signed by Employee and Health care provider:

  1. Section I: EmployerEmployer (or employee)
  2. Section II: EmployeeEmployee
  3. Section III: Health care provider's detailsHealth care provider
  4. Part A: Medical informationHealth care provider
  5. Part B: Amount of leave neededHealth care provider

Fill out Form WH-380-F online with FileIt

  1. Pick the person. Choose someone from People and FileIt fills in their name, date of birth, address and other details it already knows.
  2. Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 64 fields in all. Your answers save as you go.
  3. Check the live preview. Watch your answers land on the real U.S. Department of Labor, Wage and Hour Division form, and let FileIt do any worksheet arithmetic.
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Official sources

FileIt is not affiliated with or endorsed by U.S. Department of Labor, Wage and Hour Division or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts.

Fill out Form WH-380-F online