Book a Demo
U.S. Department of Labor, Wage and Hour Division Edition Revised June 2020 (OMB 1235-0003, expires 8/31/2029) 4 pages

Form WH-380-F — Certification of Health Care Provider for Family Member's Serious Health Condition (FMLA)

The Department of Labor's optional form for certifying that an employee needs FMLA leave to care for a spouse, parent or child with a serious health condition.

Fill Out Form WH-380-F Online View the Form Free on every VergeHR plan
Form WH-380-F · Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act
The official U.S. Department of Labor, Wage and Hour Division form, edition Revised June 2020 (OMB 1235-0003, expires 8/31/2029) — blank
Page 1 of 4
Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 1 of 4
Page 1 of 4
Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 2 of 4
Page 2 of 4
Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 3 of 4
Page 3 of 4
Form WH-380-F (2020) Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act — page 4 of 4
Page 4 of 4
Fill This Form Online Blank PDF from U.S. Department of Labor, Wage and Hour Division

What is Form WH-380-F?

When an employee asks for leave under the Family and Medical Leave Act (FMLA) to care for a family member with a serious health condition, the employer may require a medical certification from the family member's health care provider. Form WH-380-F is the Department of Labor's form for that certification. Using it is optional, but it asks for the information a complete and sufficient certification needs, and the employer may not ask for more than the FMLA regulations allow.

It has three sections. Section I is filled in by the employer or the employee: names, the date the certification was requested and the date it's due back (at least 15 calendar days later). Section II is the employee's: the family member's name, their relationship (spouse, parent, child under 18, or adult child incapable of self-care because of a disability), the care you'll give, your best estimate of the leave you need and any reduced schedule, and your signature. Section III is completed and signed by the family member's health care provider: the patient's condition and the care and leave needed.

VergeHR pre-fills your details from the People in Files, walks you through Sections I and II, lets you add Section III when the provider gives you the answers, and prints everything into the Department of Labor's own PDF. The completed form goes back to your employer, not to the Department of Labor.

Who fills it
Section I: the employer or employee. Section II: the employee, who signs. Section III: the family member's health care provider, who signs.
Returned to
The employer (the form says: do not send it to the Department of Labor; return it to the patient).
Deadline
The date the employer sets in Section I, which must be at least 15 calendar days after the request, unless that isn't feasible despite the employee's diligent, good faith efforts.
Signatures
The employee (page 2) and the health care provider (page 4).
Edition
Revised June 2020 (OMB 1235-0003, expires 8/31/2029)
Agency
U.S. Department of Labor, Wage and Hour Division

Who needs to fill out Form WH-380-F?

  • Employees asking for FMLA leave to care for a spouse, parent or child with a serious health condition, whose employer asked for a medical certification.
  • Parents caring for a child under 18, or for an adult child who can't care for themselves because of a mental or physical disability.
  • Adult children caring for a parent, including someone who stood in loco parentis to them.
  • Employers and HR teams requesting certification for family care leave.
  • Health care providers and their staff completing the certification for a patient whose relative needs leave.

When to Use Form WH-380-F

  • When an employer requires medical certification for FMLA leave to care for a family member with a serious health condition.
  • For leave because of your own serious health condition, use Form WH-380-E instead.
  • The form says an employer may not request a certification for leave to bond with a healthy newborn child or a child placed for adoption or foster care.
  • Complete and sign Section II before giving the form to your family member or their provider, and get it back to your employer by the date in Section I.

What You Need Before You Start

  • Your name, your employer's name, and the dates the certification was requested and is due.
  • Your family member's name and your relationship to them.
  • A description of the care you'll provide: basic medical, hygienic, nutritional or safety needs, transportation, physical care, psychological comfort, or other.
  • Your best estimate of the leave needed, and any reduced schedule you can work (dates, hours per day, days per week).
  • For Section III: the provider's details and their best estimate of the condition, the care needed, and the amount of leave (treatment dates, continuous incapacity, or frequency and duration of flare-ups).

What’s On Form WH-380-F

The 2020 edition has 4 pages. VergeHR asks for it in 5 parts, and it is signed by Employee and Health care provider:

  1. Section I: EmployerEmployer (or employee)
  2. Section II: EmployeeEmployee
  3. Section III: Health care provider's detailsHealth care provider
  4. Part A: Medical informationHealth care provider
  5. Part B: Amount of leave neededHealth care provider

How to fill out Form WH-380-F, step by step

1 Section I — Employer

Either the employee or the employer completes Section I: the employee's name, the employer's name, the date the certification was requested, and the date it must be returned by, at least 15 calendar days later unless that isn't feasible despite the employee's diligent, good faith efforts.

2 Section II — Employee

(1) The name of the family member you'll care for. (2) Your relationship: spouse, parent, child under 18, or child 18 or older who is incapable of self-care because of a mental or physical disability. The form explains that "spouse" includes common law and same-sex marriage, and that "parent" and "child" include in loco parentis relationships, with no legal or biological relationship needed. (3) The care you'll provide, (4) your best estimate of the leave you need, and (5) any reduced work schedule. Then sign and date.

3 Section III — Provider details and Part A

The provider gives their contact details, the patient's name, when the condition started and how long it will last, and describes the care the patient needs (for FMLA to apply, care must be medically necessary). They tick the type of serious health condition (inpatient care, incapacity plus treatment, pregnancy, chronic, permanent or long-term, multiple treatments) and may add other medical facts.

4 Part B — Amount of leave needed

The provider's best estimate of planned treatment dates, referrals to other providers, the duration of treatment and recovery, any continuous period of incapacity, and for intermittent leave how often episodes are likely over the next 6 months and how long each lasts. Then the provider signs and dates page 4.

Common Mistakes to Avoid

  • Not signing Section II before handing the form to your family member's provider.
  • Ticking the wrong relationship. An adult child qualifies only if incapable of self-care because of a mental or physical disability.
  • Leaving the estimate of leave vague: the form warns that "lifetime", "unknown" or "indeterminate" may not be sufficient.
  • Missing the return date in Section I. An incomplete or late certification may lead to the leave request being denied.
  • Sending the form to the Department of Labor. It goes back to the employer.
  • Using this form for your own condition. That's Form WH-380-E.

After You Fill It Out

Sign Section II (by hand, or send it for signature from VergeHR), then give the form to your family member or their health care provider to complete and sign Section III. VergeHR keeps a copy of the filled PDF in Files.

Return the completed certification to your employer by the date in Section I. You're responsible for making sure it reaches the employer in time.

The employer must keep medical certifications confidential and separate from the usual personnel files, and the form's burden statement says employers must keep a copy for three years.

Fill Out Form WH-380-F Online with VergeHR

  1. Pick the employee. Choose an employee and VergeHR fills in their name, date of birth, email and other details it already knows.
  2. Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 64 fields in all. Your answers save as you go.
  3. Check the live preview. Watch your answers land on the real U.S. Department of Labor, Wage and Hour Division form, and let VergeHR do any worksheet arithmetic.
  4. Generate the official PDF. VergeHR prints your answers into the agency’s own PDF and files it with that employee’s documents. Sign it, or send it for e-signature.

VergeHR fills the form — it never files or submits anything for you. Deliver the finished form to whoever asked for it, the way the form’s instructions say.

Start Form WH-380-F Now — It’s Free

Form WH-380-F: frequently asked questions

Can I fill out Form WH-380-F online?

Yes. VergeHR guides you through Sections I and II, and Section III if you have the provider's answers, and prints them into the Department of Labor's official PDF, saved in Files. You and the provider still sign it.

Which family members does WH-380-F cover?

A spouse, a parent, a child under 18, or a child 18 or older who is incapable of self-care because of a mental or physical disability. Parent and child include in loco parentis relationships.

Is the form required?

The form itself is optional: an employer may use its own, as long as it asks only for what the FMLA regulations allow. But if the employer requires certification, you must provide a complete and sufficient one in time, or the leave request may be denied.

How long do I have to return it?

At least 15 calendar days from the date the employer requested it; the exact date is in Section I.

Where does the completed form go?

Back to your employer. The form says in bold: do not send the completed form to the Department of Labor.

What's the difference between WH-380-F and WH-380-E?

WH-380-F is for leave to care for a family member. WH-380-E is for the employee's own serious health condition.

Official Sources

VergeHR is not affiliated with or endorsed by U.S. Department of Labor, Wage and Hour Division or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-09-28.

Fill Out Form WH-380-F Online