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

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This form contains 71 fields organized into 16 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 additional information if necessary.
3ef9 Text
Provide any additional relevant information as required.
undefined Text
Provide any additional relevant information as required.
Care Details
treatment and recovery. Provide your best estimate of the beginning date Text
Provide your best estimate of the beginning date for the treatment and recovery period.
end date Text
Provide the estimated end date for the treatment and recovery period.
any period(s) of recovery Text
Specify any periods of recovery that are expected during the treatment.
times Text
Estimate the frequency of intermittent care over the next 6 months.
undefined Text
Provide any additional relevant information regarding the care or treatment.
Care Frequency
III C 9 D/W/M_DAY RadioButton
Select this option if the care is needed on a daily, weekly, or monthly basis.
III C 9 D/W/M_WEEK RadioButton
Select this option if the care is needed on a weekly basis.
III C 9 D/W/M_MONTH RadioButton
Select this option if the care is needed on a monthly basis.
III C 9 H/D_HOURS RadioButton
Select this option if the care is needed for a certain number of hours per day.
III C 9 H/D_DAYS RadioButton
Select this option if the care is needed for a certain number of days.
Eligibility
NONE OF THE ABOVE. Note to Employee: If this box is checked, you may still be eligible to take leave to care for CheckBox
Check this box if none of the specified conditions apply, but you believe you may still be eligible for leave to care for a servicemember.
Employee Information
First Text
Enter your first name.
1 Employee name Text
Enter your full name.
1 Employee name Text
Enter the full name of the employee requesting leave.
Text
Enter the area code for the employee's contact number.
Area Code Text
Enter the area code for the employee's contact number.
1 Employee name Text
Enter the full name of the employee requesting leave.
Employer Information
(2) Employer name Text
Enter the name of your employer.
General Information
Date Text
Enter the current date in the format mm/dd/yyyy.
3) This certification must be returned by Text
Enter the date by which this certification must be returned.
Date Text
Enter the current date.
Healthcare Provider
Provider signature Signature
Signature of the healthcare provider certifying the need for leave.
Healthcare Provider Information
Health Care Provider's Name: (Print) Text
Enter the full name of the healthcare provider who is certifying the servicemember's medical condition.
Health Care Provider's business address Text
Enter the business address of the healthcare provider.
Type of practice/Medical specialty Text
Enter the type of practice or medical specialty of the healthcare provider.
E-mail Text
Enter the email address of the healthcare provider.
DOD health care provider CheckBox
Check this box if the healthcare provider is a Department of Defense (DOD) healthcare provider.
VA health care provider CheckBox
Check this box if the healthcare provider is a Veterans Affairs (VA) healthcare provider.
DOD TRICARE network authorized private health care provider CheckBox
Check this box if the healthcare provider is a DOD TRICARE network authorized private healthcare provider.
DOD non-network TRICARE authorized private health care provider CheckBox
Check this box if the healthcare provider is a DOD non-network TRICARE authorized private health care provider.
Health care provider as defined in 29 C.F.R. § 825.125 CheckBox
Check this box if the healthcare provider meets the definition as outlined in 29 C.F.R. § 825.125.
Leave Information
7) Give your best estimate of the amount of leave needed to provide the care described Text
Give your best estimate of the amount of leave needed to provide the care described.
Give your best estimate of the amount of leave needed to provide the care described [2 Text
Give your best estimate of the amount of leave needed to provide the care described.
Medical Information
(2) List the approximate date condition started or will start Text
Provide 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 is expected to last.
If yes, briefly describe the medical treatment, recuperation or therapy Text
If applicable, briefly describe the medical treatment, recuperation, or therapy the servicemember is undergoing.
III B 5_IS#20NOT RadioButton
Select this option if the condition is not related to the servicemember's duty.
III B 4_INCURRED#20ON#20DUTY RadioButton
Select this option if the condition was incurred on duty.
III B 5_IS RadioButton
Select this option if the condition is related to the servicemember's duty.
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 applicable.
VSI) Very Seriously Ill/Injured Illness/Injury is of such a severity that life is imminently endangered. Family CheckBox
Check this box if the servicemember is very seriously ill or injured, with an illness/injury of such severity that life is imminently endangered.
SI) Seriously Ill/Injured Illness/injury is of such severity that there is cause for immediate concern, but there CheckBox
Check this box if the servicemember is seriously ill or injured, with an illness/injury of such severity that there is cause for immediate concern.
OTHER Ill/Injured A serious injury or illness that may render the servicemember medically unfit to perform CheckBox
Check this box if the servicemember has a serious injury or illness that may render them medically unfit to perform their duties.
Nature of Care
Assistance with basic medical, hygienic, nutritional, or safety needs CheckBox
Check this box if you will be providing assistance with basic medical, hygienic, nutritional, or safety needs.
Psychological Comfort CheckBox
Check this box if you will be providing psychological comfort.
Transportation CheckBox
Check this box if you will be providing transportation.
Physical Care CheckBox
Check this box if you will be providing physical care.
Other CheckBox
Check this box if you will be providing other types of care not listed.
Relationship to Servicemember
II A 2_SPOUSE RadioButton
Select this option if you are the spouse of the servicemember.
II A 2_PARENT RadioButton
Select this option if you are the parent of the servicemember.
II A 2_CHILD RadioButton
Select this option if you are the child of the servicemember.
II A 2_NEXT#20OF#20KIN RadioButton
Select this option if you are the next of kin of the servicemember.
Servicemember Information
PART A: EMPLOYEE INFORMATION Text
Enter the name of the current servicemember for whom you are requesting leave.
Reserves. If yes, provide the servicemember’s military branch, rank and unit currently assigned to [1 Text
If the servicemember is in the Reserves, provide their military branch, rank, and unit currently assigned to.
Reserves. If yes, provide the servicemember’s military branch, rank and unit currently assigned to [2 Text
If the servicemember is in the Reserves, provide their military branch, rank, and unit currently assigned to.
facility or unit Text
Enter the facility or unit where the servicemember is currently assigned.
(1) Patient's Name Text
Enter the full name of the patient (servicemember) receiving care.
Servicemember's Medical Status
II B 3_IS RadioButton
Select this option if the servicemember is currently undergoing medical treatment, recuperation, or therapy.
II B 3_IS#20NOT RadioButton
Select this option if the servicemember is not currently undergoing medical treatment, recuperation, or therapy.
II B 4_0 ComboBox
Select this option if the servicemember's injury or illness was incurred in the line of duty.
II B 4_1 ComboBox
Select this option if the servicemember's injury or illness was not incurred in the line of duty.
II B 4_2 ComboBox
Select this option if the servicemember's injury or illness was aggravated in the line of duty.
II B 4_3 ComboBox
Select this option if the servicemember's injury or illness was not aggravated in the line of duty.
Work Schedule
schedule you are able to work. From Text
Enter the schedule you are able to work, starting from the specified date.
(mm/dd/yyyy) to Text
Enter the date range in the format mm/dd/yyyy.
able to work Text
Enter the number of hours you are able to work per day.
(hours per day) Text
Enter the number of hours you are able to work per day.