Form WH-380-E: FMLA Certification of Health Care Provider for Employee's Serious Health Condition
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JustFill is not affiliated with U.S. Department of Labor, Wage and Hour Division. This is an independent third-party tool to help you complete WH-380-E. Always download the current blank form from the official source and verify your completed copy before signing or submitting. Official WH-380-E from U.S. Department of Labor, Wage and Hour Division
Form WH-380-E is the U.S. Department of Labor certification employers may require when an employee requests FMLA leave for their own serious health condition. The employer completes its section, the employee fills in their information, and the health care provider certifies the medical facts. The employee has 15 calendar days to return it to the employer. With JustFill you upload the blank WH-380-E PDF, the AI auto-detects every field, you type or dictate your details, and you download the completed form free.
When you request FMLA leave for your own serious health condition, your employer may ask you to support it with Form WH-380-E from the DOL Wage and Hour Division. JustFill makes the official PDF fillable in your browser, so the employee and provider sections come back typed and legible instead of handwritten. The employer states the employee's job and essential functions, the employee completes their identifying information, and the health care provider certifies the medical facts — when the condition began, treatment, and how it limits the employee's ability to work, including any need for intermittent or reduced-schedule leave. Employers must allow at least 15 calendar days for the completed certification to come back, and they cannot demand more information than the form itself asks for.
What each section of WH-380-E asks for. JustFill’s AI will detect these fields automatically when you upload the PDF — review the breakdown below so you know what to enter.
Employer contact details plus the employee's job title, schedule, and essential job functions.
Your name and basic identifying information, completed before you hand the form to your provider.
The health care provider's name, practice type, address, and contact details.
When the condition began, how long it is expected to last, and relevant treatment — only what FMLA allows.
Whether the employee can perform the essential job functions and what they are unable to do.
Continuous, intermittent, or reduced-schedule leave, with estimated frequency and duration of episodes.
The certifying provider signs and dates the completed medical portion.
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Official source: WH-380-E on U.S. Department of Labor, Wage and Hour Division’s website
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