Form WH-385-V, Certification for Serious Injury or Illness Instructions
This form contains 71 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| undefined | Text |
Provide any additional information or details as required.
|
| Care Duration | ||
| and are likely to last approximately | Text |
Provide an estimate of how long the care sessions are likely to last.
|
| Care Frequency | ||
| e.g. 3 days/week | Text |
Specify the frequency of care needed, e.g., 3 days per week.
|
| Over the next 6 months, intermittent care is estimated to occur | Text |
Estimate how often intermittent care will be needed over the next 6 months.
|
| III C 3 D/W/M_0 | ComboBox |
Select this option if the care frequency is measured in days per week, month, or year.
|
| III C 3 D/W/M_1 | ComboBox |
Select this option if the care frequency is measured in days per week, month, or year.
|
| III C 3 D/W/M_2 | ComboBox |
Select this option if the care frequency is measured in days per week, month, or year.
|
| III C 3 H/D_HOURS | RadioButton |
Select this option if the care frequency is measured in hours per day.
|
| III C 3 H/D_DAYS | RadioButton |
Select this option if the care frequency is measured in days.
|
| Care Needs | ||
| Assistance with basic medical, hygienic, nutritional, or safety needs | CheckBox |
Check this box if the veteran requires assistance with basic medical, hygienic, nutritional, or safety needs.
|
| Transportation | CheckBox |
Check this box if the veteran requires assistance with transportation.
|
| Psychological Comfort | CheckBox |
Check this box if the veteran requires psychological comfort.
|
| Physical Care | CheckBox |
Check this box if the veteran requires physical care.
|
| Other | CheckBox |
Check this box if the veteran requires other types of assistance not listed.
|
| Certification Details | ||
| List date certification requested | Text |
List the date when the certification was requested.
|
| Employee Information | ||
| Employee Name | Text |
Enter the full name of the employee requesting leave.
|
| Employee Name | Text |
Enter the full name of the employee requesting leave.
|
| II A 2_SPOUSE | RadioButton |
Select this option if you are the spouse of the covered veteran.
|
| II A 2_PARENT | RadioButton |
Select this option if you are the parent of the covered veteran.
|
| II A 2_CHILD | RadioButton |
Select this option if you are the child of the covered veteran.
|
| II A 2_NEXT#20OF#20KIN | RadioButton |
Select this option if you are the next of kin of the covered veteran.
|
| Employee Name | Text |
Enter the name of the employee requesting leave.
|
| Employee Name | Text |
Enter the full name of the employee requesting leave.
|
| Employer Details | ||
| 2) Employer Name | Text |
Enter the name of your employer.
|
| General Information | ||
| Date | Text |
Enter the current date in mm/dd/yyyy format.
|
| Health Care Provider Certification | ||
| DOD health care provider | CheckBox |
Check this box if you are a Department of Defense (DOD) health care provider.
|
| VA health care provider | CheckBox |
Check this box if you are a Veterans Affairs (VA) health care provider.
|
| DOD TRICARE network authorized private health care provider | CheckBox |
Check this box if you are a DOD TRICARE network authorized private health care provider.
|
| DOD non-network TRICARE authorized private health care provider | CheckBox |
Check this box if you are a DOD non-network TRICARE authorized private health care provider.
|
| Health care provider as defined in 29 CFR 825.125 | CheckBox |
Check this box if you are a health care provider as defined in 29 CFR 825.125.
|
| 1) Patient’s Name | Text |
Enter the name of the patient (covered veteran).
|
| 2) List the approximate date condition started or will start | Text |
List the approximate date when the condition started or will start.
|
| 3) Provide your best estimate of how long the condition will last | Text |
Provide your best estimate of how long the condition will last.
|
| describe the medical treatment, recuperation, or therapy [1 | Text |
Describe the medical treatment, recuperation, or therapy (part 1).
|
| describe the medical treatment, recuperation, or therapy [2 | Text |
Describe the medical treatment, recuperation, or therapy (part 2).
|
| HCP SIGNATURE | Signature |
Health care provider's signature.
|
| DATE SIGNED | Text |
Enter the date the form was signed by the health care provider.
|
| Health Care Provider Information | ||
| Provider's name | Text |
Enter the full name of the health care provider who is certifying the need for leave.
|
| Provider address | Text |
Provide the complete address of the health care provider.
|
| HCP specialty | Text |
Specify the specialty of the health care provider (e.g., cardiology, neurology).
|
| HCP area code | Text |
Enter the area code for the health care provider's phone number.
|
| HCP Phone | Text |
Provide the phone number of the health care provider.
|
| HCP fax AC | Text |
Enter the area code for the health care provider's fax number.
|
| HCP Fax | Text |
Provide the fax number of the health care provider.
|
| HCP email | Text |
Enter the email address of the health care provider.
|
| Leave Details | ||
| 7) Give your best estimate of the amount of FMLA leave needed to provide the care described | Text |
Estimate the amount of FMLA leave needed to provide the care described.
|
| 8) If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work | Text |
If a reduced work schedule is necessary to provide the care described, give your best estimate of the reduced work schedule.
|
| schedule you are able to work. From | Text |
Specify the start date of the reduced work schedule.
|
| mm/dd/yyyy) to | Text |
Specify the end date of the reduced work schedule.
|
| able to work | Text |
Specify the number of hours you are able to work per day.
|
| hours per day | Text |
Specify the number of hours you are able to work per day.
|
| Veteran Information | ||
| Veteran's full name | Text |
Enter the full name of the veteran for whom the leave is being requested.
|
| Guard or Reserves. List the date of the veteran’s discharge | Text |
If the veteran was part of the Guard or Reserves, list the date of their discharge.
|
| 4) Please provide the veteran’s military branch, rank and unit at the time of discharge | Text |
Provide the veteran's military branch, rank, and unit at the time of discharge.
|
| 5) The veteran | Text |
Provide details about the veteran's condition or status.
|
| II B 3_HONORABLE | RadioButton |
Select this option if the veteran was discharged under honorable conditions.
|
| II B 3_DISHONORABLE | RadioButton |
Select this option if the veteran was discharged under dishonorable conditions.
|
| II B 5_IS | RadioButton |
Select this option if the veteran is currently a member of the Armed Forces.
|
| II B 5_IS#20NOT | RadioButton |
Select this option if the veteran is not currently a member of the Armed Forces.
|
| Veteran's Condition Details | ||
| III B 4_ON#20DUTE | RadioButton |
Select this option if the condition is related to an on-duty injury or illness.
|
| III B 4_PRE#20EXISTING | RadioButton |
Select this option if the condition is pre-existing.
|
| III B 4_N#2FA | RadioButton |
Select this option if the condition is not related to a specific factor.
|
| III B 4 PART 2_0 | ComboBox |
Select this option if it applies to the veteran's condition (Part 2, Option 0).
|
| III B 4 PART 2_1 | ComboBox |
Select this option if it applies to the veteran's condition (Part 2, Option 1).
|
| A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member | CheckBox |
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.
|
| A physical or mental condition for which the covered veteran has received a U.S. Department of Veterans Affairs | CheckBox |
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.
|
| A physical or mental condition that substantially impairs the covered veteran’s ability to secure or follow a | CheckBox |
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.
|
| An injury, including a psychological injury, on the basis of which the covered veteran is enrolled in the Department | CheckBox |
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.
|
| None of the above. Note to Employee: If this box is checked, you may still be eligible to take leave to care for a covered | CheckBox |
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.
|
| Veteran's Recovery Information | ||
| recovery. Provide your best estimate of the beginning date | Text |
Provide your best estimate of the beginning date of the veteran's recovery.
|
| mm/dd/yyyy) and end date | Text |
Enter the end date of the veteran's recovery period in the format mm/dd/yyyy.
|