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WH-380-F form (FMLA certification for a family member'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-F, Certification of Health Care Provider for Family Member's Serious Health Condition, has three sections: the employer's, the employee's (the family member and the care they will give), and the family member's health care provider. It is returned to the patient, not the DOL.

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At a glance

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

Who uses it

Employers
Employees caring for a family member
The family member's health care provider

Sections

Section I: Employer: Employer name, date requested, and the return-by date.
Section II: Employee: The family member's name, their relationship to you (spouse, parent, child), and the care you will give. Complete and sign it before giving the form to the provider.
Section III: Health care provider, Part A: Medical information: when the condition started, how long it lasts, and which serious-health-condition category applies.
Section III: Health care provider, Part B: The amount of care needed: treatment dates, periods of incapacity, and the frequency and duration of episodes.

Questions

Who fills out WH-380-F?

The employer completes Section I, the employee Section II, and the family member's health care provider Section III.