Form WH-380-E, Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act Completed Form Examples and Samples
Browse a realistic filled Form WH-380-E example (FMLA medical certification) for an employee’s serious health condition. This sample Certification of Health Care Provider shows how to document surgery, recovery dates, incapacity period, treatment plan, follow-up visits, and intermittent leave for physical therapy—formatted like the official WH-380-E under the Family and Medical Leave Act.
Form WH-380-E Example – Employee’s Serious Health Condition (Post-Operative Recovery)
How this form was filled:
This Form WH-380-E example shows a realistic FMLA medical certification for an employee who had knee surgery and needs continuous leave for recovery followed by intermittent leave for physical therapy and follow-up appointments. It includes the provider’s contact details, approximate condition dates, medical facts (without overly sensitive detail), incapacity period, treatment schedule, and an estimate of intermittent absences.
Information used to fill out the document:
- Form Name: WH-380-E — Certification of Health Care Provider for Employee’s Serious Health Condition (FMLA)
- Employee First Name: Jordan
- Employee Last Name: Reed
- Employee Date of Birth: 1990-08-14
- Employee Job Title: Warehouse Team Lead
- Employer Name: North River Logistics, Inc.
- Employer Contact (HR): Maya Chen, HR Leave Specialist
- Employer Phone: 415-555-0138
- Employer Fax: 415-555-0199
- Employer Address: 2450 Harbor Park Blvd, Oakland, CA 94607
- Health Care Provider Name: Dr. Aisha Patel, MD
- Provider Specialty: Orthopedic Surgery
- Medical Practice / Clinic: Bayview Orthopedics & Sports Medicine
- Provider Address: 780 Market Street, Suite 1200, San Francisco, CA 94102
- Provider Phone: 415-555-0172
- Provider Fax: 415-555-0184
- Provider Email: [email protected]
- Provider License / NPI (example): NPI 1234567890
- Date Certification Completed: 2026-01-08
- Serious Health Condition Type (general): Condition requiring surgery and continuing treatment
- Condition (non-sensitive description): Post-operative recovery following arthroscopic knee surgery (right knee)
- Approximate Date Condition Began (symptoms/diagnosis): 2025-12-10
- Surgery Date: 2025-12-20
- First Treatment / Evaluation Date: 2025-12-12
- Planned Follow-Up Visit Dates: 2026-01-12; 2026-02-09
- Physical Therapy Start Date: 2026-01-13
- Physical Therapy Frequency/Duration: 2 sessions per week for 8 weeks
- Incapacity Start Date: 2025-12-20
- Incapacity End Date (estimated): 2026-01-30
- Able to Work During Incapacity: No
- Need for Reduced Schedule After Incapacity: Yes
- Reduced Schedule Start Date: 2026-02-02
- Reduced Schedule End Date (estimated): 2026-03-27
- Reduced Schedule Details: Max 6 hours/day, avoid lifting >15 lbs, limited standing/walking; desk or light-duty work only if available
- Intermittent Leave Needed: Yes
- Intermittent Leave Reason: Physical therapy sessions and periodic flare-ups during recovery
- Estimated Intermittent Absences (appointments): 2 times per week, 1.5–2 hours per episode (PT)
- Estimated Intermittent Absences (flare-ups): Up to 1 episode per week, 4–8 hours per episode
- Overnight/Extended Treatments Expected: No (outpatient surgery completed; no inpatient stay expected)
- Medication / Treatment (general): Post-op pain management, anti-inflammatory medication, structured physical therapy program
- Provider Statement (work limitations): Employee is unable to perform essential functions requiring prolonged standing, walking, climbing, squatting, or heavy lifting during recovery period
- Essential Job Functions Provided to Provider: Frequent lifting 30–50 lbs; standing/walking most of shift; climbing ladders; operating pallet jacks
- Provider Signature Name (typed for example): Aisha Patel, MD
- Provider Signature Date: 2026-01-08
What this filled form sample shows:
- SEO-targeted, realistic Form WH-380-E example using near-current 2025–2026 dates
- Shows a common FMLA scenario: surgery + recovery with continuous leave followed by intermittent leave for PT
- Includes provider certification elements: condition timeline, treatment plan, and estimated incapacity
- Demonstrates how to describe medical facts at a practical level (e.g., post-op recovery) without unnecessary sensitive detail
- Provides clear intermittent leave frequency and duration estimates for appointments and flare-ups
Form specifications and details:
| Form Number: | WH-380-E |
| Form Title: | Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act |
| Use Case: | Employee requires FMLA leave after outpatient knee surgery with ongoing physical therapy |
| Leave Type Illustrated: | Continuous leave followed by intermittent/reduced-schedule leave |
| Jurisdiction: | United States (FMLA) |
| Year of Example Dates: | 2025–2026 |
| Notes: | This is a fictional sample dataset for rendering a completed WH-380-E form as a web page. Values are illustrative and not medical or legal advice. |
Created: January 16, 2026 07:13 AM
