Yes! You can use AI to fill out Form WH-380-E, Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act
Form WH-380-E is a U.S. Department of Labor Wage and Hour Division form used when an employer requests medical certification for an employee’s own serious health condition under the FMLA. It captures key information from a health care provider about the condition, expected duration, need for continuous or intermittent leave, and any work restrictions or inability to perform essential job functions. A timely, complete, and sufficient certification helps determine whether the leave qualifies for FMLA protections and helps avoid delays or denial of the leave request. The completed form is returned to the patient/employee (not sent to the Department of Labor) and should be maintained by the employer as a confidential medical record.
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Form specifications
| Form name: | Form WH-380-E, Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act |
| Number of fields: | 77 |
| Number of pages: | 4 |
| Field instructions: | WH-380-E Instructions |
| Filled form examples: | Form WH-380-E Examples |
| Language: | English |
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Follow these steps to fill out your WH-380-E form online using Instafill.ai:
- 1 Confirm you are using Form WH-380-E (employee’s own serious health condition) and note the employer’s deadline for returning the certification (at least 15 calendar days from the request date, unless not feasible).
- 2 Complete Section I (Employer) with the employee name, employer name, date certification was requested, return-by date, job title, work schedule, and attach/provide the job description or essential job functions if available.
- 3 Enter the health care provider’s contact details in Section II (provider name, address, specialty, phone/fax/email) and verify the patient/employee information.
- 4 Fill out Part A (Medical Information): provide the condition start date, expected duration, and check the applicable serious health condition category (e.g., inpatient care, incapacity plus treatment, pregnancy, chronic, permanent/long-term, multiple treatments) and add any other appropriate medical facts if needed.
- 5 Complete Part B (Amount of Leave Needed): list planned treatment dates, referrals and treatment timelines, any reduced schedule needs, continuous incapacity dates, and/or intermittent leave frequency and duration estimates.
- 6 Complete Part C (Essential Job Functions) by identifying at least one essential job function the employee cannot perform due to the condition (using the employer’s job functions statement if provided).
- 7 Have the health care provider sign and date the form, then return the completed certification to the patient/employee for submission to the employer (do not send it to the Department of Labor).
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Frequently Asked Questions About Form WH-380-E
Form WH-380-E is a medical certification used to support an employee’s request for FMLA leave due to the employee’s own serious health condition. It provides the employer with the information needed to determine whether the leave qualifies for FMLA protection.
Section I may be completed by the employee or the employer. Section II (Parts A–C) must be completed and signed by the employee’s health care provider.
Do not send the completed form to the U.S. Department of Labor. The completed form should be returned to the patient (employee), who then provides it to the employer.
The employer must give you at least 15 calendar days to return the certification from the date it was requested. The due date is typically listed in Section I, item (3).
If you do not provide a timely, complete, and sufficient certification, your employer may deny your FMLA leave request. If something prevents timely return despite diligent, good-faith efforts, communicate with your employer as soon as possible.
Section I includes the employee’s name, employer name, the date certification was requested, the deadline to return it, the employee’s job title, regular work schedule, and (optionally) a job description and essential job functions.
No—providers may include other appropriate medical facts (such as symptoms or treatment regimen), but they are not required to provide a diagnosis. Some state or local laws may also limit what private medical information can be disclosed.
For FMLA purposes, a serious health condition generally involves inpatient care (an overnight stay) or continuing treatment by a health care provider. The form lists common categories such as incapacity plus treatment, pregnancy, chronic conditions, permanent/long-term conditions, and conditions requiring multiple treatments.
The provider should list when the condition started, how long it is expected to last, and check the box(es) that best describe the type of serious health condition. If none of the categories apply, the provider can skip to the signature section as instructed.
Part B asks the provider to estimate the timing and amount of leave needed, such as dates of planned treatments, referrals, continuous incapacity dates, reduced schedule needs, or intermittent absences. Estimates should be as specific as possible rather than “unknown” or “indeterminate.”
The provider should estimate how often episodes of incapacity will occur (per day/week/month) and how long each episode will likely last (hours/days), typically looking ahead over the next 6 months. This is used to evaluate intermittent FMLA leave needs for episodic flare-ups.
A reduced schedule means the employee can work fewer hours than normal due to the condition. The provider should estimate the start and end dates for the reduced schedule and the hours the employee can work (e.g., 5 hours/day or up to 25 hours/week).
Part C asks whether the employee cannot perform one or more essential job functions due to the condition and to identify at least one function affected. The employer may provide a job description/essential functions in Section I, but if not, the provider may rely on the employee’s description.
No. The form states employers may not request a medical certification for FMLA leave taken to bond with a healthy newborn or a child placed for adoption or foster care.
Yes. The form instructs providers not to include genetic information, such as genetic tests, genetic services, or information about diseases/disorders in the employee’s family members, consistent with GINA-related rules.
Compliance WH-380-E
Validation Checks by Instafill.ai
1
Employee Name Completeness (First and Last Required)
Validates that the Employee name field includes at least a non-empty first and last name (middle optional) and does not contain placeholder text (e.g., 'N/A', 'unknown'). This is necessary to correctly associate the certification with the correct employee and avoid misfiling confidential medical records. If validation fails, the submission should be flagged as incomplete and returned for correction before processing.
2
Employer Name Present and Non-Placeholder
Checks that the Employer name is provided and is not a generic or placeholder value (e.g., 'company', 'same as above', 'N/A'). Employer identification is required to route the certification to the correct organization and maintain proper recordkeeping. If missing or invalid, the form should be rejected or held until a valid employer name is supplied.
3
Section I Date Requested Format and Valid Calendar Date
Ensures the 'Date certification requested' is present and follows mm/dd/yyyy with a real calendar date (e.g., not 02/30/2026). This date drives statutory timing requirements and downstream validations (e.g., the 15-day return window). If invalid, the system should block submission or require correction because compliance calculations cannot be performed.
4
Return-By Date Format and Minimum 15-Day Rule
Validates that the 'medical certification must be returned by' date is in mm/dd/yyyy format and is at least 15 calendar days after the 'date requested' (unless an exception workflow is explicitly captured elsewhere). This is a core FMLA requirement stated on the form and helps prevent unlawful deadlines. If the return-by date is earlier than allowed, the system should flag it for HR review and require an updated date or documented exception.
5
Job Title and Work Schedule Required When Employer Completes Section I
Checks that Employee job title and regular work schedule are provided when Section I is being completed by the employer/employee (and not left blank). These fields support later determinations about essential functions and reduced schedule requests. If missing, the submission should be marked incomplete and routed back for completion because Part C may be impossible to evaluate accurately.
6
Job Description Attachment Indicator Consistency
Validates that the 'Job description is/is not attached' selection is explicitly made and consistent with any uploaded attachment metadata (if the system supports file uploads). This prevents situations where the provider is expected to rely on essential functions but no description is actually available. If inconsistent (e.g., marked 'attached' but no file), the system should prompt for the missing attachment or require the indicator to be corrected.
7
Health Care Provider Identity and Contact Information Completeness
Ensures the Health Care Provider’s printed name and business address are present, and at least one reliable contact method is provided (telephone required; fax/email optional but validated if present). This is important for authentication, follow-up questions, and preventing fraudulent or unverifiable certifications. If missing, the form should be rejected as insufficient because the employer cannot validate or clarify the certification.
8
Provider Contact Format Validation (Phone/Fax/Email)
Validates that telephone and fax numbers contain valid digits and length (e.g., 10 digits for US numbers, allowing punctuation), and that email (if provided) matches a standard email format. Correct formatting reduces failed outreach attempts and ensures the provider can be contacted promptly within FMLA timelines. If formatting fails, the system should require correction or normalize the value (where permitted) before acceptance.
9
Condition Start Date Format and Logical Placement
Checks that the approximate date the condition started/will start is a valid mm/dd/yyyy date and is not unreasonably far in the future/past relative to the certification date (configurable tolerance). This date anchors the medical timeline and supports consistency checks with incapacity and treatment periods. If invalid or illogical, the submission should be flagged for correction or manual review.
10
Condition Duration Provided and Not Indeterminate Without Detail
Validates that the estimated duration (how long the condition lasted/will last) is provided and is not solely 'unknown/indeterminate/lifetime' without additional qualifying detail elsewhere in Part B. The form explicitly notes that vague durations may be insufficient to determine FMLA coverage. If the duration is missing or too vague, the system should mark the certification as potentially insufficient and request clarification.
11
Part A Category Selection and Required Detail Triggering
Ensures that at least one Part A option is selected (Inpatient Care, Incapacity plus Treatment, Pregnancy, Chronic, Permanent/Long Term, Multiple Treatments, or 'None of the above'). For each selected category, the system should enforce completion of the corresponding required dates/details (e.g., inpatient admission dates; incapacity from/to dates; expected delivery date). If a category is checked without required supporting details, the submission should fail validation as incomplete.
12
Incapacity Date Range Validity (From/To) and Minimum >3 Full Days Rule
When 'Incapacity plus Treatment' is selected, validates that the incapacity 'from' and 'to' dates are valid, the 'to' date is on/after the 'from' date, and the span reflects more than three consecutive full calendar days as stated on the form. This ensures the certification aligns with the regulatory definition and prevents approving leave based on an invalid timeline. If the range is too short or reversed, the system should flag the certification as inconsistent and require correction or review.
13
Treatment/Visit Dates Present When Required by Selected Condition Type
If 'Incapacity plus Treatment' is selected, validates that at least one provider visit date is listed, and if a continuing treatment regimen is indicated, that the regimen indicator is explicitly marked (has/has not). This supports the definition of continuing treatment and helps determine whether the condition qualifies. If visit dates are missing or the regimen indicator is not selected, the submission should be flagged as insufficient.
14
Part B Leave Type Consistency (Continuous vs Reduced vs Intermittent)
Validates that Part B entries are internally consistent: continuous incapacity (Q8) should not conflict with a reduced schedule (Q7) or intermittent episodes (Q9) without clear non-overlapping date ranges or explanatory detail. This prevents ambiguous leave administration and payroll/attendance errors. If conflicting leave types are entered with overlapping dates and no clarification, the system should require the submitter to correct or add clarifying information.
15
Reduced Schedule Details Required (Dates and Work Capacity)
When Q7 indicates a reduced schedule is medically necessary, validates that both 'from' and 'to' dates are provided and that the employee’s work capacity is specified in measurable terms (e.g., hours/day or hours/week). This is necessary to administer partial-day leave accurately and to calculate FMLA usage. If dates or measurable capacity are missing, the system should mark the reduced schedule request as incomplete.
16
Intermittent Leave Frequency/Duration Completeness and Units
When Q9 intermittent leave is indicated, validates that frequency includes a numeric value and a selected unit (day/week/month) and that duration includes a numeric value and a selected unit (hours/days). This prevents unusable entries like 'as needed' without quantification and supports scheduling and FMLA tracking. If any component is missing or non-numeric, the system should reject the intermittent leave section and request a best-estimate entry.
17
Provider Signature and Signature Date Required
Ensures the Health Care Provider signature is present and the signature date is a valid mm/dd/yyyy date (and not earlier than key medical timeline entries by an unreasonable margin, configurable). A signed certification is required for authenticity and enforceability. If missing or invalid, the certification should be treated as not received/insufficient and returned for completion.
Common Mistakes in Completing WH-380-E
People often overlook the bold instruction that the form should NOT be sent to the U.S. Department of Labor and must be returned to the patient/employee. Sending it to the wrong place delays the certification process and can cause the employee to miss the employer’s deadline, risking denial of FMLA leave. To avoid this, follow the routing instruction on the form: the provider returns it to the patient (or per employer instructions), not to DOL.
A frequent error is leaving Section I fields blank (employee name, employer name, job title) or entering names that don’t match HR records (nicknames, missing middle initial when used by employer systems, etc.). This can cause HR to reject the certification as incomplete or be unable to match it to the correct leave request. Use the employee’s legal name as used by the employer and ensure the employer name and job title match internal records.
The form repeatedly requires dates in mm/dd/yyyy, but people enter other formats (dd/mm/yyyy), write only month/year, or leave dates blank. Incorrect or partial dates create ambiguity about when the condition began, treatment occurred, or incapacity applies, which can lead to follow-up requests and delays. Always enter full dates in mm/dd/yyyy and double-check that start/end dates are chronologically logical.
Employers sometimes fill Section I(3) with a deadline that is fewer than 15 calendar days from the request date, or they forget to complete it at all. This can create disputes, rework, and confusion for the provider and employee, and may undermine enforceability of the deadline. To avoid this, calculate at least 15 calendar days from the request date (unless not feasible despite diligent efforts) and clearly write the due date.
Providers sometimes omit business address, specialty, phone/fax/email, or write it in a way that HR cannot read. When employers need clarification (which FMLA rules allow in limited ways), missing contact details can stall the process and lead to an “incomplete certification” determination. Print clearly and provide at least one reliable contact method (phone and/or fax/email) plus practice address and specialty.
A very common mistake is checking boxes like “Incapacity plus Treatment,” “Chronic Conditions,” or “Multiple Treatments” in Part A, but leaving Part B blank or too vague. The form explicitly requires the amount of leave needed in Part B for all checked boxes, and missing this can cause the certification to be deemed insufficient and trigger re-certification requests. After selecting any Part A category, complete the relevant Part B items with frequency, duration, and date ranges.
Providers often use non-specific language when estimating how long the condition will last or how often intermittent leave is needed. The form warns that terms like “unknown” or “indeterminate” may be insufficient to determine FMLA coverage, which can lead to denial or requests for clarification. Provide best estimates with measurable ranges (e.g., “1–2 episodes/month, lasting 1–2 days each” or “reduced schedule 4 hours/day for 6 weeks”).
In Part B(9), people frequently forget to circle/select the unit (day/week/month) or the duration unit (hours/days), or they enter numbers without specifying the unit. This makes it impossible for the employer to translate the certification into an attendance/leave plan and often results in follow-up. Always provide both frequency and duration with units (e.g., “2 times per month, 4 hours per episode”).
Another frequent issue is entering incapacity start/end dates that don’t align with the stated onset date, inpatient admission date, or scheduled treatment dates (e.g., incapacity ending before it begins, or treatment occurring outside the claimed incapacity window). Inconsistencies raise red flags and can cause HR to treat the certification as unreliable or incomplete. Review all dates together before signing to ensure the timeline is coherent and medically consistent.
Part C(10) is often skipped, or the provider writes a generic statement like “cannot work” without identifying at least one essential function the employee cannot perform. Employers use this section to connect the medical condition to work limitations; missing specifics can lead to clarification requests or disputes about whether leave is medically necessary. Identify at least one concrete essential function (e.g., “cannot lift 30 lbs,” “cannot stand for prolonged periods,” “cannot perform direct patient care during flare-ups”).
Some providers include genetic test results, family medical history, or other genetic information even though the form explicitly instructs not to provide it, and employers must comply with GINA/ADA confidentiality rules. This can create legal risk for both provider and employer and may require redaction and re-submission, delaying approval. Limit responses to the condition(s) relevant to the leave request and avoid genetic tests/services or family-member manifestations; include diagnosis only if permitted and necessary.
A surprisingly common error is completing the medical sections but forgetting to sign and date the certification on page 4. An unsigned/undated form is typically treated as incomplete and can lead to denial if not corrected within the allowed timeframe. Always sign and date in mm/dd/yyyy after confirming all required sections are complete.
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