No credit card required. Upload your PDF and start filling in seconds.
Form WH-380-E is the medical certification form used under the Family and Medical Leave Act (FMLA) when an employee requests leave for their own serious health condition. The employee's healthcare provider completes this form to certify the medical necessity of the leave, including the expected duration and whether intermittent leave is needed.
Section I (Employee): Enter your name, the name of your employer, and your job title.
Provide the form to your healthcare provider to complete the remaining sections.
Section II (Healthcare Provider): Enter patient name, diagnosis, and date the condition began.
Indicate whether the employee is currently incapacitated and unable to work.
Specify whether the condition requires inpatient care or continuing treatment.
If intermittent leave is needed, provide the probable frequency and duration of episodes.
Estimate the expected duration of the condition and leave needed.
The healthcare provider must sign and date the form with their credentials and contact information.
Skip the manual work — let AI fill Form WH-380-E for you
Eligible employees are entitled to up to 12 workweeks of unpaid, job-protected leave in a 12-month period for their own serious health condition. Some employers offer paid FMLA leave as a benefit.
Your employer may contact your healthcare provider for clarification or authentication of the certification, but the contact must be made by a health care provider, HR professional, or management official — not your direct supervisor.
If the certification is complete and sufficient, the employer must grant the leave. If denied, you can file a complaint with the U.S. Department of Labor's Wage and Hour Division or consult an employment attorney.
Upload your Form WH-380-E PDF and let AI detect every field automatically. Fill it in seconds — no watermarks, no Adobe, no hassle.
GDPR compliant. No credit card required.