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.
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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.
The official 4-page Form WH-380-E PDF is free to download from the U.S. Department of Labor Wage and Hour Division at dol.gov/agencies/whd/fmla/forms. Upload the blank WH-380-E PDF to JustFill on this page so the employer, employee, and health care provider sections can be typed cleanly in your browser and downloaded with no Adobe Acrobat required.
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.
A fictional HR coordinator prepares Section I of Form WH-380-E for an employee requesting 6 weeks of continuous FMLA leave following orthopedic surgery.
Sample Cascade Logistics Inc. · HR Dept, 500 Harbor Blvd, Seattle, WA 98104
Completed by the employer before handing the form to the employee.
Warehouse Shift Supervisor · 40 hrs/week (Mon–Fri, 7:00 AM – 3:30 PM) · Essential job functions attached
Allows the health care provider to evaluate which job duties the employee cannot perform.
Completed by Dr. Rebecca Sample, MD (Orthopedic Surgery) · Hospitalization/Recovery: 10/20/2026 – 12/01/2026
Documents the qualifying serious health condition without requiring a specific ICD diagnosis code.
Continuous leave from 10/20/2026 through 12/01/2026 (6 weeks) plus 2 follow-up PT appointments
Specifies continuous incapacity dates and follow-up treatment schedule.
These values are made up. They are here to show what belongs on each line, not to be copied — every name, number, and address on your own WH-380-E has to be your own.
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Official source: WH-380-E on U.S. Department of Labor, Wage and Hour Division’s website
Edition checked: OMB Control Number 1235-0003 (Expires 06/30/2026). Verified against the official source on · Verified in our Government Forms Fillability Study.
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WH-380-E
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