Form WH 380-E, Certification of Health Care Provider for Employee's Serious Health Condition, is a form used by employers and sent to the US Department of Labor, Wages and Hour Division. This form verifies that an employee has a serious medical condition. It documents certain information about the employer, the employee, and the healthcare provider treating the employee. The employer fills out their portion and then provides the form to the employee. After the employee fills out their information, they provide the form to their medical provider who completes it. This document must be completed and returned to the employer so that the employee's leave can be approved.
Table of Contents
This form is used by the United States Department of Labor, Wages and Hour Division. A Form WH 380-E is known as a Certification of Health Care Provider for Employee’s Serious Health Condition. This form will be used to verify the medical condition of an employee. Three parties will need to fill out different sections of the form: the employer, the employee, and the health care provider.
The employer will be the first person to fill out the form. They will need to include their own information, as well as information about the employee. That includes their job title and their work schedule. Next, the employee needs to list their full name. The last section is completed by a healthcare professional. This section will detail the serious health condition. The medical professional will need to include documentation of the illness so that the employee’s leave can be approved.
To complete a Form WH 380-E, you will need to provide the following information
Section I: For Completion by the Employer
Section II: For Completion by the Employee
Section III: For Completion by the Health Care Provider
