Fill Out DOL Form WH-380-E Online
Certification of Health Care Provider for Employee's Serious Health Condition (FMLA)
U.S. Department of Labor
Certifies an employee's own serious health condition to support FMLA leave.
Reviewed July 2026
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Form WH-380-E is the Department of Labor's model certification form used when an employee requests leave under the Family and Medical Leave Act (FMLA) for their own serious health condition. A health care provider completes the medical portion so the employer can confirm the leave qualifies for FMLA protection.
You can complete the WH-380-E in the Universal PDF editor. Fill in the employer and employee sections before handing it to the health care provider, or type the provider's responses into a clean copy, then download the finished PDF for the employer's FMLA file.
What is Form WH-380-E used for
When an employee asks for FMLA leave because of their own serious health condition, the employer may require a medical certification to support the request. The WH-380-E is the DOL's optional model form for that certification: it asks the health care provider to describe the condition, the expected duration, and whether the employee needs continuous leave, intermittent leave, or a reduced schedule.
Use of this specific form is voluntary. Employers may use their own certification forms, but they cannot demand more information than the FMLA regulations allow, and the completed certification stays with the employer rather than being sent to the Department of Labor.
Who completes Form WH-380-E
Three parties typically touch the form:
- The employer fills in Section I, identifying the employee and listing the essential functions of the job.
- The employee completes Section II with their own identifying information and returns the form to their health care provider.
- The health care provider completes Section III, describing the medical facts, treatment schedule, and expected frequency and duration of the leave.
How to fill out Form WH-380-E
Employers should complete their portion before giving the form to the employee, because the provider's answers depend on the job duties described. The provider then indicates the date the condition began, its probable duration, planned treatment, and whether the employee is unable to perform job functions.
For intermittent or reduced-schedule leave, the provider estimates the frequency and duration of flare-ups or appointments. Vague or incomplete answers can lead the employer to request a corrected certification, so specific responses save everyone time.
Deadlines and retention rules
Under the FMLA regulations, an employer that wants certification generally must request it within five business days of the leave request, and the employee must be given at least 15 calendar days to return the completed form. If the certification is incomplete, the employer must identify what is missing and give the employee a chance to cure it.
Completed medical certifications are confidential. Employers keep them in files separate from the regular personnel file, consistent with FMLA and ADA confidentiality rules, and retain FMLA records for at least three years.
Frequently asked questions
No. It is the DOL's optional model form. Employers may use their own certification form, but they cannot require more information than FMLA regulations permit.
Employees generally must be given at least 15 calendar days to return the completed certification after the employer requests it.
The employee's health care provider completes the medical section. The employer completes its own section first, and the employee fills in their identifying information.
No. The completed certification is returned to the employer and kept in confidential employer records. Nothing is filed with the DOL.
WH-380-E certifies the employee's own serious health condition. WH-380-F certifies a family member's serious health condition when the employee needs leave to provide care.
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