Form WH 380 F—Certification of Health Care Provider for Family Member’s Serious Health Condition under the FMLA is for employees who need to leave to take care of a family member.
Fill out Form WH 380 F. If you’re an employee, you can fill out both Sections I and II. However, Section II must be filled out by the employee as it requires the employee’s signature. Section I, on the other hand, do not require the employer’s signature.
After these parts of Form WH 380 F is done, it must be filled out by the healthcare provider. This part of Form WH 380 F is going to work as a certification. Do not mail Form WH 380 F to the Department of Labor. Give it to your employer after all the parts of it is filled out. Your employer will keep Form WH 380 F for the records in case it’s needed.
Start filling out the fillable Form WH 380 F below. You can then download it as PDF and e-mail it to your healthcare provider. You have the option to print out a paper copy and fill out with the healthcare provider but it might not be optional due to the coronavirus pandemic.
Fillable Form WH 380 F 2024
Under the FMLA—Family and Medical Leave Act, employees are eligible for up to 12 weeks of leave. For this, the employee must be working for a covered employer and you must meet the FMLA requirements. Before you file Form WH 380 F, we suggest figuring out whether or not you’re eligible.
What is a covered employer?
The covered employer is an employer whom employers 50 or more employees. For the FMLA purposes, if an employer employs at least 50 employees for 20 or more weeks in the previous or current calendar year, the employer is a covered employer. In addition to this, the employer must have at least 50 or more employees living in a 75-mile radius of the worksite.
Other than this, the employee must qualify for leave under the FMLA. All employees must meet the following to leave under the FMLA.
- The employee must be working for at least 12 months prior to the leave.
- The employee must have worked for at least 1,250 hours in the past 12 months. This equates to about 24 hours per week.
As long as these are met, the employee is eligible for leave under the FMLA. File Form WH 380 F to leave under the FMLA for a family member. To learn more about other things related to FMLA such as an employer denying leave and other FMLA forms, read this article.