WH-380-F, the FMLA form for a family member's care

What is the WH-380-F form?

The WH-380-F certifies a family member's serious health condition when you need leave to care for them under the Family and Medical Leave Act (FMLA). It is an optional Department of Labor form. Under 29 CFR 825.305(a), your employer decides whether to ask for a certification. On the WH-380-F, it comes from your family member's health care provider.

Under 29 CFR 825.306(b), your employer may use the Department of Labor's optional form or another form with the same basic information, but it may not require information beyond what the regulations allow. Those limits run from 825.306 through 825.308.

Under 29 CFR 825.110 you are eligible if you work for a covered employer, at a worksite with 50 or more of its employees within 75 miles, and you have 12 months of employment with that employer and 1,250 hours of service in the 12 months before your leave begins. Eligibility is necessary and not sufficient: your family member must also have a serious health condition and need your care, and your employer must designate the leave as FMLA leave. Our guide sets out what counts as a serious health condition.

WH-380-F or WH-380-E: which one do you need?

It depends on who the patient is. For leave to care for a family member, it is the WH-380-F. For your own serious health condition, 825.306(b) points to the WH-380-E: "Optional form WH-380E is for use when the employee's need for leave is due to the employee's own serious health condition."

Under 825.306(a)(4), a certification for your own condition addresses whether you can perform the essential functions of your job. Under (a)(5), a certification for a family member addresses whether they need care. That is why the WH-380-E's provider section has a Part C on job functions and the WH-380-F's stops at Part B. The section numbers differ too: the provider's section is Section II on the WH-380-E and Section III on the WH-380-F.

Our guide to the WH-380-E covers that form.

Who counts as a family member for the WH-380-F?

29 CFR 825.112(a)(3) gives the leave reason: "To care for the employee's spouse, son, daughter, or parent with a serious health condition." 29 CFR 825.122 defines each of those terms.

A spouse is a husband or wife. Under 825.122(b), that includes a same-sex or common law marriage entered into in a state that recognizes it, or one entered into outside any state that is valid where it was entered into and could have been entered into in at least one state.

A parent is a biological, adoptive, step or foster father or mother, or anyone who stood in loco parentis to you when you were a child. 825.122(c) is explicit: "This term does not include parents 'in law.'"

Under 825.122(d), a son or daughter can be a biological or adopted child, a foster child, a stepchild, a legal ward, or a child of a person standing in loco parentis. The child must be under age 18, or age 18 or older and "incapable of self-care because of a mental or physical disability" at the time FMLA leave is to commence.

Under 825.122(d)(3), people in loco parentis include those with day-to-day responsibilities to care for and financially support a child. "A biological or legal relationship is not necessary."

Siblings, grandparents and other relatives are not named in these definitions. A relative counts only where the relationship fits one of them: a grandparent who adopted you, or who stood in loco parentis to you when you were a child, counts as a parent under 825.122(c).

Who fills out each section of the WH-380-F?

Section I is headed "Employer," but the form says: "Either the employee or the employer may complete Section I." It carries your name and your employer's, along with the date the certification was requested and the date it must be returned by.

Section II is yours: "Please complete and sign Section II before providing this form to your family member or your family member's health care provider."

Section III belongs to your family member's health care provider, because your family member is the patient. The provider completes what applies in Part A and Part B, and signs.

The form tells the provider to return the completed form to the patient, your family member. It does not go straight to your employer. 29 CFR 825.306 says it directly: it is the employee's responsibility to provide the employer with complete and sufficient certification.

The form calls for a health care provider, and 29 CFR 825.125 sets who counts. The list is wider than physicians. Nurse practitioners and physician assistants are at (b)(2).

Certicare is a telehealth service where leave and accommodation paperwork is completed and signed by a state-licensed provider after an evaluation. On the WH-380-F, that is Section III, where the evaluation supports it, usually within 24 hours after we have everything needed. The family member who needs care goes through the intake and is evaluated as the patient.

There's usually no appointment, and a provider may follow up for more detail before deciding. Completing our intake form starts the review; it does not guarantee a signature, and if the review does not support your request you are refunded in full.

The medical leave forms page sets out what Certicare completes.

What does Section II ask about the care you'll provide?

Section II asks for the name of the family member you'll care for and your relationship to them, from the form's relationship boxes. It then asks for a brief description of the care you'll provide, with check boxes labeled "Assistance with basic medical, hygienic, nutritional, or safety needs," "Transportation," "Physical Care," "Psychological Comfort" and "Other."

It asks for your best estimate of the amount of leave needed to provide that care and, if a reduced work schedule is necessary, of the reduced schedule you're able to work. Then you sign.

29 CFR 825.124 sets what "care" means here: being needed to care for a family member "encompasses both physical and psychological care." Under 825.124(b), you need not be the only person available to give that care.

Under 825.124(c), intermittent or reduced-schedule leave can also cover care you share with another family member or a third party. Intermittent FMLA explained goes further.

What does the provider's section ask for?

29 CFR 825.306(a) lists what an employer may require a certification to set out. Section III asks for the provider's contact details, then Part A and Part B.

Part A: Medical Information

Part A asks for medical facts about the condition. Under 825.306(a)(3), those medical facts "may include" a diagnosis. A diagnosis is not required on the certification.

Part A also asks for the patient's name, and when the condition started or will start and how long it lasted or will last. It asks what type of care the patient needs, and the form notes: "For FMLA to apply, care of the patient must be medically necessary." It then asks which of the form's serious-health-condition categories apply.

Part B: Amount of Leave Needed

Part B asks about planned treatment and referrals to other providers, and about any continuous period of incapacity. It also asks whether it is medically necessary for you, the employee, to be absent intermittently to provide care, with an estimate of the frequency and duration.

What goes in each Part is the provider's judgment, made after the evaluation.

When is the WH-380-F due?

The deadline runs from your employer's request. Section I carries both dates, the day your employer asked and the day the form must be returned, and the form says your employer must give you at least 15 calendar days. Under 29 CFR 825.305(b), the certification is due "within 15 calendar days after the employer's request, unless it is not practicable under the particular circumstances to do so despite the employee's diligent, good faith efforts or the employer provides more than 15 calendar days to return the requested certification."

The same clocks apply to the WH-380-E and the WH-380-F. Can FMLA be backdated covers late certification, and the WH-380-E guide covers a certification your employer finds incomplete or insufficient.

The FMLA does not require a provider to complete the form. If your family member's provider won't, doctor won't fill out FMLA paperwork covers the next steps. If your employer denies the leave, the guide to FMLA denials covers what comes next.

Your family member goes through the intake as the patient, and a state-licensed provider completes and signs Section III, where the evaluation supports it.