Form · Leave

WH-380-E form (FMLA certification for an employee's serious health condition)

What it is, who uses it, and field-by-field help. Publisher: U.S. Department of Labor, Wage and Hour Division. Links checked October 23, 2026.

Quick answer

WH-380-E, Certification of Health Care Provider for Employee's Serious Health Condition, has an employer section and a health care provider section with medical facts, the amount of leave needed, and whether the employee can do their job. The provider returns it to the patient, not the DOL.

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At a glance

Form: WH-380-E, revised June 2020
OMB number: 1235-0003
Pages: 4
Return to: The patient
Get the form: WH-380-E (PDF)

Who uses it

Employers
Employees asking for leave for their own condition
The employee's health care provider

Section I: Employer

(1) to (3) Employee, employer, due date: Employee name, employer name, date requested, and the return-by date (at least 15 calendar days out).
(4) Job title and essential functions: Job title, schedule, and the essential functions, or an attached job description.

Section II: Health care provider

Provider details: Name, business address, type of practice, phone, fax, and email.
Part A (1) to (4): Medical information: When the condition started, how long it will last, and which serious-health-condition category applies (inpatient care, incapacity plus treatment, pregnancy, chronic condition, and others). Genetic information is not allowed.
Part B (5) to (9): Amount of leave: Planned treatment dates, referrals, any reduced schedule, a period of incapacity, and the frequency and duration of flare-ups.
Part C (10): Essential job functions: Whether the employee can perform one or more essential functions.
Signature: The health care provider signs and dates.

Questions

Does the provider have to give a diagnosis on WH-380-E?

No. The form says providers may, but are not required to, give other medical facts such as a diagnosis, and some state laws limit what can be disclosed.