Your employer CANNOT contact your doctor directly — they can only request clarification through you

If your employer challenges the certification, they may request a second opinion at their expense

You can take FMLA intermittently (e.g., 2 hours per week for treatment appointments)

Employment / FMLAmoderateDoctor signature required

FMLA Certification - Employee's Serious Health Condition

WH-380-E · U.S. Department of Labor

Certification of Health Care Provider for Employee's Serious Health Condition. Medical certification for FMLA leave for the employee's own condition.

Form Details

Total fields: 40
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Filled by: doctor
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Where to Submit This Form

📬

Return to your employer's HR department

Hand-deliver or mail to HR. Keep a copy with your delivery confirmation.

📧

Email to HR if your employer accepts electronic submissions

Filing Deadline

Within 15 calendar days of your employer's request for medical certification.

Required Attachments

📎 Must be completed and signed by your healthcare provider
📎 Supporting medical records if employer requests clarification

Processing Time

Employer must notify you of approval/denial within 5 business days of receiving the completed certification.

What Happens Next

If approved, your FMLA leave is job-protected for up to 12 weeks in a 12-month period. Your employer cannot retaliate against you for taking FMLA leave.

Tips for This Form

✓ Your employer CANNOT contact your doctor directly — they can only request clarification through you
✓ If your employer challenges the certification, they may request a second opinion at their expense
✓ You can take FMLA intermittently (e.g., 2 hours per week for treatment appointments)
✓ File a complaint with the DOL Wage and Hour Division if your employer violates FMLA: https://www.dol.gov/agencies/whd/contact/complaints

More Employment / FMLA Forms

FMLA Certification - Family Member's Serious Health Condition

WH-380-F · U.S. Department of Labor

Certification of Health Care Provider for Family Member's Serious Health Condition. Medical certification when employee needs leave to care for a family member.

FMLA Notice of Eligibility and Rights & Responsibilities

WH-381 · U.S. Department of Labor

Notice of Eligibility and Rights & Responsibilities. Employer must provide within 5 business days of FMLA leave request, stating whether employee is eligible.

FMLA Designation Notice

WH-382 · U.S. Department of Labor

Designation Notice. Employer designates leave as FMLA-qualifying or denies it. Must be provided within 5 business days of receiving sufficient certification.

FMLA Certification - Qualifying Exigency (Military)

WH-384 · U.S. Department of Labor

Certification of Qualifying Exigency for Military Family Leave. For leave due to a covered family member's active duty or call to active duty.

FMLA Certification - Serious Injury/Illness of Servicemember

WH-385 · U.S. Department of Labor

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (current servicemember).

FMLA Certification - Serious Injury/Illness of Veteran

WH-385-V · U.S. Department of Labor

Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the U.S. Department of Labor or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.