This form contains 85 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Certification Details
Date (mm/dd/yyyy) List date certification requested	Text	Enter the date when the certification was requested in mm/dd/yyyy format.
The medical certification must be returned by (mm/dd/yyyy)	Text	Enter the date by which the medical certification must be returned in mm/dd/yyyy format.
Employee Information
Employee name First	Text	Enter the first name of the employee requesting leave.
Employee name Middle	Text	Enter the middle name of the employee requesting leave.
Employee name Last	Text	Enter the last name of the employee requesting leave.
Employee Name	Text	Enter the name of the employee requesting leave.
Employee Signature	Signature	Employee must sign here to certify the information provided.
Date (mm/dd/yyyy)	Text	Enter the date of the employee's signature in the format mm/dd/yyyy.
Employee Name	Text	Enter the name of the employee requesting leave.
Employee Name	Text	Enter the full name of the employee requesting FMLA leave.
Employer Information
Employer name	Text	Enter the name of the employer.
Family Member Information
Name of the family member for whom you will provide care	Text	Enter the name of the family member for whom you will provide care.
Family Member Relationship
Relationship of the family member to you_Spouse	CheckBox	Check this box if the family member is your spouse.
Relationship of the family member to you_Parent	CheckBox	Check this box if the family member is your parent.
Relationship of the family member to you_Child,#20under#20age#2018	CheckBox	Check this box if the family member is your child under the age of 18.
Relationship of the family member to you_Child,#20age#2018#20or#20older#20and#20incapable#20of#20self-care#20because#20of#20a#20mental#20or#20physical#20disability	CheckBox	Check this box if the family member is your child aged 18 or older and incapable of self-care because of a mental or physical disability.
Health Care Provider Information
Health Care Provider’s name: (Print)	Text	Print the name of the health care provider.
Health Care Provider’s business address	Text	Enter the business address of the health care provider.
Type of practice / Medical specialty	Text	Specify the type of practice or medical specialty of the health care provider.
Telephone	Text	Enter the telephone number of the health care provider.
Fax	Text	Enter the fax number of the health care provider.
E-mail	Text	Enter the email address of the health care provider.
Signature of Health Care Provider	Signature	Provide the signature of the health care provider.
Date (mm/dd/yyyy)	Text	Provide the date when the form is signed in the format mm/dd/yyyy.
Incapacity Duration
are likely to last approximately	Text	Provide an estimate of how long each episode of incapacity is likely to last.
per episode_hours	CheckBox	Indicate if each episode of incapacity is likely to last a certain number of hours.
per episode_days	CheckBox	Indicate if each episode of incapacity is likely to last a certain number of days.
Incapacity Frequency
Over the next 6 months, episodes of incapacity are estimated to occur	Text	Provide an estimate of how often episodes of incapacity are expected to occur over the next 6 months.
times per_day	CheckBox	Indicate if episodes of incapacity are expected to occur times per day.
times per_week	CheckBox	Indicate if episodes of incapacity are expected to occur times per week.
times per_month	CheckBox	Indicate if episodes of incapacity are expected to occur times per month.
Leave Duration
Provide your best estimate of the beginning date (mm/dd/yyyy)	Text	Provide your best estimate of the beginning date of the leave in the format mm/dd/yyyy.
end date (mm/dd/yyyy)	Text	Provide your best estimate of the end date of the leave in the format mm/dd/yyyy.
Leave Estimate
Give your best estimate of the amount of leave needed to provide the care described	Text	Provide your best estimate of the amount of leave needed to provide the care described.
Leave Period
From (mm/dd/yyyy)	Text	Enter the start date of the leave period in the format mm/dd/yyyy.
to (mm/dd/yyyy)	Text	Enter the end date of the leave period in the format mm/dd/yyyy.
Medical Condition Details
Conditions requiring Multiple Treatments: (e.g. chemotherapy treatments, restorative surgery) Due to the condition, it is medically necessary for the patient to receive multiple treatments	CheckBox	Check this box if the patient's condition requires multiple treatments, such as chemotherapy or restorative surgery.
None of the above: If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy) no additional information is needed. Go to page 4 to sign and date the form	CheckBox	Check this box if none of the specified conditions (e.g., inpatient care, pregnancy) apply. If checked, proceed to page 4 to sign and date the form.
If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks FMLA leave. (e.g., use of nebulizer, dialysis)	Text	Provide a brief description of other relevant medical facts related to the condition for which the employee is seeking FMLA leave, such as the use of a nebulizer or dialysis.
Due to the condition, the patient_had	CheckBox	Check this box if the patient had a condition that required medical attention.
Due to the condition, the patient_will#20have	CheckBox	Check this box if the patient will have a condition that requires medical attention.
8Due to the condition, the patient_was	CheckBox	Check this box if the patient was affected by the condition.
8Due to the condition, the patient_will#20be	CheckBox	Check this box if the patient will be affected by the condition.
State the nature of such treatments: (e.g. cardiologist, physical therapy)	Text	State the nature of the treatments the patient is receiving, such as visits to a cardiologist or physical therapy sessions.
Medical Information
admitted for an overnight stay in a hospital, hospice, or residential medical care facility on the following date(s)	Text	Enter the date(s) when the patient was admitted for an overnight stay in a hospital, hospice, or residential medical care facility.
Incapacity plus Treatment: (e.g. outpatient surgery, strep throat)	CheckBox	Check this box if the patient's condition involves incapacity plus treatment, such as outpatient surgery or strep throat.
Due to the condition, the patient_has#20been	CheckBox	Check this box if the patient has been affected due to the condition.
Due to the condition, the patient_is#20expected#20to#20be	CheckBox	Check this box if the patient is expected to be affected due to the condition.
consecutive, full calendar days from (mm/dd/yyyy)	Text	Enter the start date (mm/dd/yyyy) for the consecutive full calendar days the patient will be affected.
to (mm/dd/yyyy)	Text	Enter the end date (mm/dd/yyyy) for the consecutive full calendar days the patient will be affected.
The patient_was	CheckBox	Check this box if the patient was affected due to the condition.
The patient_will#20be	CheckBox	Check this box if the patient will be affected due to the condition.
enter dates	Text	Enter the relevant dates as required.
dates	Text	Enter the relevant dates as required.
The condition_has	CheckBox	Check this box if the condition has affected the patient.
The condition_has#20not	CheckBox	Check this box if the condition has not affected the patient.
Pregnancy: The condition is pregnancy	CheckBox	Check this box if the condition is pregnancy.
List the expected delivery date	Text	List the expected delivery date if the condition is pregnancy.
Chronic Conditions: (e.g. asthma, migraine headaches) Due to the condition, it is medically necessary for the patient to have treatment visits at least twice per year	CheckBox	Check this box if the patient has a chronic condition (e.g., asthma, migraine headaches) that requires treatment visits at least twice per year.
Permanent or Long Term Conditions: (e.g. Alzheimer’s, terminal stages of cancer) Due to the condition, incapacity is permanent or long term and requires the continuing supervision of a health care provider (even if active treatment is not being provided)	CheckBox	Check this box if the patient has a permanent or long-term condition (e.g., Alzheimer’s, terminal stages of cancer) that requires continuing supervision of a health care provider.
Medical Treatment Schedule
planned medical treatment(s) (scheduled medical visits) (e.g. psychotherapy, prenatal appointments) on the following date(s)	Text	List the dates of planned medical treatments or scheduled medical visits, such as psychotherapy or prenatal appointments.
planned medical treatment(s) (scheduled medical visits) (e.g. psychotherapy, prenatal appointments) on the following date(s)	Text	List additional dates of planned medical treatments or scheduled medical visits, such as psychotherapy or prenatal appointments.
Provide your best estimate of the beginning date (mm/dd/yyyy)	Text	Provide your best estimate of the beginning date of the treatment in the format mm/dd/yyyy.
and end date	Text	Provide your best estimate of the end date of the treatment.
Provide your best estimate of the duration of the treatment(s), including any period(s) of recovery (e.g. 3 days/week)	Text	Provide your best estimate of the duration of the treatment(s), including any periods of recovery, such as 3 days per week.
Patient Care
For FMLA to apply, care of the patient must be medically necessary. Briefly describe the type of care needed by the patient (e.g., assistance with basic medical, hygienic, nutritional, safety, transportation needs, physical care, or psychological comfort)	Text	Briefly describe the type of care needed by the patient, such as assistance with basic medical, hygienic, nutritional, safety, transportation needs, physical care, or psychological comfort.
Patient Condition
State the approximate date the condition started or will start (mm/dd/yyyy)	Text	State the approximate date when the patient's condition started or will start in the format mm/dd/yyyy.
3 Provide your best estimate of how long the condition lasted or will last	Text	Provide your best estimate of how long the patient's condition lasted or will last.
Inpatient Care	CheckBox	Check this box if the patient requires inpatient care.
The patient_has#20been	CheckBox	Check this box if the patient has been receiving care.
The patient_is#20expected#20to#20be	CheckBox	Check this box if the patient is expected to receive care.
9Due to the condition the patient_was	CheckBox	Indicate if the patient was affected by the condition in the past.
9Due to the condition the patient_will#20be	CheckBox	Indicate if the patient will be affected by the condition in the future.
10 Due to the condition it_was	CheckBox	Indicate if the condition affected the patient in the past.
10 Due to the condition it_is	CheckBox	Indicate if the condition is currently affecting the patient.
10 Due to the condition it_will#20be	CheckBox	Indicate if the condition will affect the patient in the future.
Patient Information
Patient’s Name	Text	Enter the name of the patient (family member with a serious health condition).
Type of Care
Assistance with basic medical, hygienic, nutritional, or safety needs	CheckBox	Check this box if you will assist with basic medical, hygienic, nutritional, or safety needs.
Transportation	CheckBox	Check this box if you will provide transportation.
Physical Care	CheckBox	Check this box if you will provide physical care.
Psychological Comfort	CheckBox	Check this box if you will provide psychological comfort.
other	CheckBox	Check this box if you will provide other types of care not listed.
Other	Text	Specify other types of care you will provide.
Work Capacity
able to work (hours per day)	Text	Specify the number of hours per day the employee is able to work.
able to work (hours per day)	Text	Specify the number of hours per day the employee is able to work.

Form WH-380-F, Certification of Health Care Provider Instructions