Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act
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JustFill is not affiliated with U.S. Department of Labor (DOL). This is an independent third-party tool to help you complete Form WH-380-F. Always download the current blank form from the official source and verify your completed copy before signing or submitting. Official Form WH-380-F from U.S. Department of Labor (DOL)
Form WH-380-F is the U.S. Department of Labor's FMLA Certification of Health Care Provider for a Family Member's Serious Health Condition. The employee completes Section II about the family member and care needed, and the family member's health care provider completes Section III with the medical certification. JustFill lets you fill it online for free, then download the PDF.
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Form WH-380-F is the FMLA Certification of Health Care Provider for Family Member's Serious Health Condition, an optional U.S. Department of Labor form employers can use when an employee requests FMLA leave to care for a family member with a serious health condition. It gathers the medical certification an employer is allowed to require under the Family and Medical Leave Act. The form has three sections: Section I, where the employer lists the employee, the date the certification was requested, and the return deadline; Section II, where the employee names the family member, their relationship, the care to be provided, and the leave estimate; and Section III, where the family member's health care provider gives the medical certification in Part A (medical information) and Part B (amount of leave needed). The current edition is revised June 2020 (OMB 1235-0003). With JustFill, the AI detects each field on the PDF, so you or the provider can type or dictate answers, handle scanned copies, and finish without Adobe Acrobat.
The official WH-380-F PDF is free to download from the U.S. Department of Labor Wage and Hour Division at dol.gov/agencies/whd/fmla/forms. JustFill opens that same PDF in your browser so the employee and provider can fill it and download a completed copy with no Adobe Acrobat required.
What each section of Form WH-380-F 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.
Employee name, employer name and date the certification was requested, and the date the certification must be returned by.
Name of the family member needing care and whether they are your spouse, parent, or child.
The care you will provide (basic needs, transportation, physical care, psychological comfort, other) and your best estimate of leave needed, including any reduced schedule.
Health care provider's name, business address, type of practice or specialty, telephone, fax, and email.
Patient name, when the condition started, how long it will last, the type of care needed, and which condition category applies (inpatient, chronic, pregnancy, etc.).
Planned treatments, referrals, periods of incapacity, and any intermittent or episodic flare-up estimates tied to the condition.
The employee's signature and date completing Section II before passing the form to the provider.
The provider's signature and date certifying the medical information in Section III.
A fictional employee and their parent's oncologist complete Form WH-380-F to support intermittent FMLA leave to transport and care for a parent undergoing chemotherapy.
Employer: Sample Summit Healthcare · Employee: SAMPLE, DANIEL P · Relationship to Patient: Son (Parent)
Completed by the employer and employee to establish a qualifying FMLA family relationship.
Patient: SAMPLE, MARGARET E · Requires assistance with transportation and post-infusion recovery
Confirms the family member requires care from the employee.
Intermittent care needed: 2 days per treatment cycle every 3 weeks from 10/15/2026 to 04/15/2027
Provides the frequency and duration of intermittent family care leave.
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 Form WH-380-F has to be your own.
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Official source: Form WH-380-F on U.S. Department of Labor (DOL)’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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