DOL Form WH-380-F: FMLA Certification for Family Member's Health Condition
Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act. Required when an employee requests FMLA leave to care for a qualifying family member.
What is Form WH-380-F?
Form WH-380-F is the Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act (FMLA). Employers may require employees to provide this completed certification when requesting FMLA leave to care for a qualifying family member with a serious health condition.
Who Uses This Form?
- Employees requesting FMLA leave to care for a spouse, child, or parent with a serious health condition provide this form to the family member's healthcare provider
- Healthcare providers of the family member complete the medical portions
- Employers use the certification to assess FMLA eligibility and authorize leave
Qualifying Family Members
Under federal FMLA, employees may take leave to care for:
- Spouse (includes same-sex spouses)
- Son or daughter (biological, adopted, foster, stepchild, legal ward, or child for whom the employee stands in loco parentis; for adult children, must have a disability or serious health condition)
- Parent (biological or legal parent, or someone who stood in loco parentis)
Sections of the Form
Section I — Employee and Family Member Information
- Completed by the employer or employee
- Employee's job title and description of job functions
- Name and relationship of family member requiring care
- Description of care to be provided
Section II — Health Care Provider Information
- Provider's name, address, and specialty
- Name and relationship of patient to employee
- Patient's diagnosis and ICD code
- Date condition commenced and probable duration
Section III — Medical Facts
- Description of the family member's serious health condition
- Whether the condition involves inpatient care
- Whether the condition requires ongoing treatment
- Nature and frequency of any episodic incapacitation
Section IV — Care Needs
- Whether the family member requires basic medical, hygienic, nutritional, or safety care
- Whether psychological comfort from the employee is beneficial
- Estimated need for intermittent or reduced schedule leave
- Duration of the employee's need to provide care
Key Differences from WH-380-E
| WH-380-E | WH-380-F | |
|---|---|---|
| Purpose | Employee's own condition | Family member's condition |
| Patient | The employee | Spouse, child, or parent |
| Care questions | Employee's incapacity | Employee's need to provide care |
Employer Obligations
- Notify employee of need for certification within 5 business days of the FMLA leave request
- Employee has 15 calendar days to return completed form
- Employer must respond with FMLA designation within 5 business days of receiving the completed certification
- All medical information is confidential and must be kept in separate files
Frequently Asked Questions
Can I take FMLA to care for a sibling or grandparent? Not under federal FMLA. However, some states have broader family leave laws (e.g., California, Oregon, New Jersey) that cover additional family relationships.
What if the family member's condition changes? Employers may request recertification every 6 months or when the employee requests an extension of leave, or if there are changed circumstances that may affect the duration or frequency of leave.
Can the employer contact the family member's doctor? Only to authenticate or clarify the certification — not to gather additional information. The contact must be made by a healthcare provider (not the HR department or supervisor) to comply with HIPAA.
Does the employee need to provide documentation of the family relationship? FMLA regulations don't require documentation of family relationships, but the employer may ask the employee to provide a simple statement of the family relationship.