Form WH-385-V, Certification for Serious Injury or Illness Instructions

Provide an estimate of how long the care sessions are likely to last.

Specify the frequency of care needed, e.g., 3 days per week.

Estimate how often intermittent care will be needed over the next 6 months.

Select this option if the care frequency is measured in days per week, month, or year.

Select this option if the care frequency is measured in days per week, month, or year.

Select this option if the care frequency is measured in days per week, month, or year.

Select this option if the care frequency is measured in hours per day.

Select this option if the care frequency is measured in days.

Check this box if you will provide assistance with the veteran's basic medical, hygiene, feeding/nutritional, or safety needs.

Check this box if you will provide transportation for the veteran (to appointments, errands, or other travel).

Check this box if you will provide psychological comfort or emotional support to the veteran.

Check this box if you will provide hands-on physical care for the veteran (for example, help with bathing, dressing, mobility, or wound care).

Check this box if the care you will provide is not listed above and write a description of the other care on the provided line.

Enter a brief description of any other type of care or support you will provide to the veteran that is not listed among the checkboxes.

Enter the full name of the employee requesting leave.

Enter the employee’s full name (first, middle, and last) as it should appear on the form.

Enter your best estimate of how much FMLA leave will be needed to provide the described care (for example, number of weeks, days, hours, or a short phrase such as 'intermittent' or 'to be determined').

Check this box if you are a Department of Defense (DOD) health care provider.

Check this box if you are a Veterans Affairs (VA) health care provider.

Check this box if you are a DOD TRICARE network authorized private health care provider.

Check this box if you are a DOD non-network TRICARE authorized private health care provider.

Check this box if you are a health care provider as defined in 29 CFR 825.125.

Enter the name of the patient (covered veteran).

List the approximate date when the condition started or will start.

Provide your best estimate of how long the condition will last.

Describe the medical treatment, recuperation, or therapy (part 1).

Describe the medical treatment, recuperation, or therapy (part 2).

Health care provider's signature.

Enter the date the form was signed by the health care provider.

Enter the full name of the health care provider who is certifying the need for leave.

Provide the complete address of the health care provider.

Specify the specialty of the health care provider (e.g., cardiology, neurology).

Enter the area code for the health care provider's phone number.

Provide the phone number of the health care provider.

Enter the area code for the health care provider's fax number.

Provide the fax number of the health care provider.

Enter the email address of the health care provider.

Estimate the amount of FMLA leave needed to provide the care described.

If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work schedule.

Enter the veteran's full name (first, middle, and last) for whom the employee is requesting FMLA leave.

Enter the first calendar date when the reduced work schedule will begin.

Enter the final calendar date when the reduced work schedule will end.

Enter the number of hours you can work each day under the reduced schedule.

Enter the number of days per week you are able to work under the reduced schedule (for example: 3 or 4).

Check this box if you are the veteran's spouse (husband or wife, including common-law or same-sex marriages).

Check this box if you are the veteran's parent or acted in loco parentis (assumed the obligations of a parent).

Check this box if you are the veteran's child.

Check this box if you are the veteran's next of kin (the primary or closest living relative designated as next-of-kin).

Enter the legal name of the employer or company responsible for the employee.

Enter the date the employer completed or requested this certification.

Enter the deadline date by which the completed certification must be returned to the employer, allowing at least 15 calendar days from the date requested unless not feasible.

Enter the name of the employee requesting leave.

Enter the employee's full name (first, middle, and last) as shown on employment records.

Enter the date the veteran was discharged or released from the Armed Forces. Fill only if 'Honorably discharged', 'Dishonorably discharged' is 'Yes' (any).

Check this box if the veteran was discharged or released from the Armed Forces honorably.

Check this box if the veteran was discharged or released from the Armed Forces dishonorably.

Check this box if the veteran is currently receiving medical treatment, recuperation, or therapy for an injury or illness.

Check this box if the veteran is not currently receiving medical treatment, recuperation, or therapy for an injury or illness.

Enter the branch of the Armed Forces from which the veteran was discharged (for example: Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, or Reserves). Fill only if 'Honorably discharged', 'Dishonorably discharged' is 'Yes' (any).

Enter the veteran’s rank and the full unit designation at the time of discharge (for example: 'Staff Sergeant, 2nd Battalion, 5th Infantry' or other applicable rank and unit details). Fill only if 'Honorably discharged', 'Dishonorably discharged' is 'Yes' (any).

Select this option if the condition is related to an on-duty injury or illness.

Select this option if the condition is pre-existing.

Select this option if the condition is not related to a specific factor.

Select this option if it applies to the veteran's condition (Part 2, Option 0).

Select this option if it applies to the veteran's condition (Part 2, Option 1).

Check this box if the veteran's condition is a continuation of a serious injury or illness that was incurred or aggravated when the veteran was a member of the armed forces.

Check this box if the veteran has a physical or mental condition for which they have received a U.S. Department of Veterans Affairs rating.

Check this box if the veteran has a physical or mental condition that substantially impairs their ability to secure or follow a substantially gainful occupation.

Check this box if the veteran has an injury, including a psychological injury, on the basis of which they are enrolled in the Department of Veterans Affairs.

Check this box if none of the above conditions apply. Note to Employee: If this box is checked, you may still be eligible to take leave to care for a covered veteran.

Provide your best estimate of the beginning date of the veteran's recovery.

Enter the end date of the veteran's recovery period in the format mm/dd/yyyy.