Guides · FMLA certification

Form WH-380-F, certifying a family member’s serious health condition: how to fill it out, field by field

By Kevin Lease, MD · Internal medicine · Published October 1, 2026 · Updated October 2, 2026

This is the short version. The full walkthrough, with every page of the form shown and each item marked, is on my other site, The Physician’s Back Office. Read the full WH-380-F walkthrough.

Form WH-380-F is the Department of Labor’s form for an employee who needs time off under the Family and Medical Leave Act (FMLA) to look after a family member with a serious health condition. The family member is your patient. The employee is the relative who works, wants the time off, and usually brings you the form. On the WH-380-E those two are the same person, and almost every difference between the two forms comes from that one fact.

If you need a blank copy, download the official WH-380-F from the Department of Labor (PDF). If the leave is for the employee’s own condition, the form is the WH-380-E, which I go through in the WH-380-E guide.

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You treat the family member, not the employee

The certification for this kind of leave comes from the family member’s health care provider, so it lands on you because you treat the person who is ill. You may never have met the employee, and that is normal. 29 C.F.R. § 825.305(a)

The trouble is that the person who knows the answers best is often not your patient but the caregiver. A daughter helping her mother bathe and driving her to therapy knows what help is needed, how often, and for how long each time, and those are the answers the form asks for. In my experience you need that conversation to fill the form out well. So when a relative drops the form off at the front desk, I have my staff book a visit for my patient within a couple of days and, with my patient’s permission, ask the caregiver to come too. If they cannot come, I ask them to fill in their own Section II and send a short note saying what help my patient needs, how often and how long each time. The 15 days started when HR asked for the form, not when it reached my office.

When both of them are your patients. Ask whose condition is keeping the employee from work. If the daughter needs time off to care for her mother, that is the WH-380-F, about the mother’s condition. If the daughter is ill herself and missing work because of her own symptoms, that is a separate WH-380-E about her own condition, filled out at her own visit. Nothing about one person’s health goes on the other person’s form. Both kinds of leave usually come out of the same 12 weeks in a 12-month period. 29 C.F.R. § 825.200(a)

Section II: the employee’s part

You need to recognize Section II so you know when it is missing, not so you can fill it in. In it the employee names the family member, checks how they are related (spouse, parent, child under 18, or a child 18 or older who cannot care for themselves because of a disability), checks the kinds of care they will give, estimates the time off, and writes any reduced schedule they can work. Then they sign it. Notice that last item. On the WH-380-E you certify a reduced schedule, but on this form the employee states it.

If Section II comes to you blank, leave it blank. The relationship is the employee’s own statement, and some of it is not a medical question at all. The form counts someone as a parent or child even with no legal or biological tie, and a parent-in-law does not count as a parent. Complete your section anyway and tell your patient the employee has to fill in and sign Section II before it goes to the employer. 29 C.F.R. § 825.122

Section III: your contact block and item 1

Print your name as you will sign it on page 4, then your practice address, phone, fax and email, and your type of practice or specialty. HR uses this block if they need to confirm you filled in the form or to ask what an answer means.

Item 1, the patient’s name. Write your patient’s name, the person who is ill. The trap is the header. Pages 2, 3 and 4 each start with a line marked “Employee Name”, and that line is for the relative who works, not your patient. Putting your patient’s name there instead is an easy mistake to make, and it makes the whole form look unread.

Part A: the medical facts and the care

Item 2: when did the condition start?

Your best estimate of when your patient’s condition started or will start. A month and a year is enough, and “approximately 2019” is fine for something long-standing.

Item 3: how long will it last?

This asks how long the condition will last, not how much time off the employee needs. Write a range in weeks or months, such as “three to six months”. For a condition that will not go away, “ongoing, chronic condition” is a complete answer as long as item 10 says how often and how long. I avoid “unknown”, “indeterminate” and “lifetime”, because the form itself warns that these may not be enough. HR can usually ask for a new certification about every six months anyway, so in my experience a range of no more than about six months is the simplest answer. 29 C.F.R. § 825.308

Item 4: what care does your patient need?

This box has no equivalent on the WH-380-E, and it is the reason this form exists. The form says that for FMLA to apply, care of the patient must be medically necessary. On the WH-380-E you certify that the employee cannot work. Here you certify that your patient needs someone.

I describe the care rather than the diagnosis. “Status post stroke with residual left-sided weakness” is a good clinical sentence, but it says what is wrong with your patient, not why the daughter has to be somewhere other than work. The form gives you its own vocabulary in the box, and those words match the boxes the employee checked in Section II: help with basic medical, hygiene, nutrition or safety needs, transportation, physical care, and psychological comfort. For example, “Needs help with bathing, dressing and taking medication. Cannot drive and needs transport to physical and occupational therapy three times a week. Needs supervision for safety because of fall risk.” Every phrase there is something a person has to be present to do.

A few kinds of care that clinicians may not realize are covered. Psychological comfort and reassurance count when your patient is receiving inpatient or home care, such as someone with dementia who becomes agitated and unsafe when alone. Time spent filling in for the usual caregiver counts, and so does time spent arranging a change in care, such as a move into a nursing home. The employee also does not have to be the only family member who could help. 29 C.F.R. § 825.124

Read Section II before you write item 4, so your answer does not contradict what the employee checked. If the daughter checked transport and physical care and you write “independent in daily activities”, the two parts disagree and the leave may not be approved. That does not mean you have to agree with her. If the honest answer is “needs help with transport, not with physical care”, write exactly that, because it is your signature on the form.

Item 5: which kind of condition is it?

Item 5 is the WH-380-E’s item 3 under a different number, with the same six categories, from inpatient care to conditions requiring multiple treatments. Check every box that fits and fill in the lines under each box you check. A checked box with nothing written under it is a common reason a form is not accepted, and every box you check needs its time off written in Part B. The table in the WH-380-E guide explains each box. The one difference to keep in mind is that on this form your patient does not need a job. Incapacity means being unable to work, go to school or carry on normal daily activities, so a nine-year-old with pneumonia who cannot go to school, or a retired father after a hip replacement who cannot bathe or dress without help, is incapacitated. 29 C.F.R. §§ 825.113(b), 825.114, 825.115

Item 6: anything else worth saying? (optional)

You may add facts that help explain the care your patient needs, such as symptoms, the treatment plan or equipment like a nebulizer, but the form says you are not required to, and it warns that some state and local laws may not allow you to disclose the diagnosis. As on the WH-380-E, I leave the diagnosis off and describe the symptoms and the care instead.

One instruction here reads strangely. Part A tells you not to describe the manifestation of disease in the employee’s family members, and your patient is the employee’s family member. Read literally it would rule out the whole form, and certifying your patient’s condition is the reason the form exists, so go ahead and certify it. What stays off the form is the health of anyone else in the family, such as “strong family history of stroke”, along with genetic test results and genetic counseling. The federal Genetic Information Nondiscrimination Act (GINA) is why. 29 C.F.R. §§ 825.306, 1635.3

Part B: how much time off

Item 7: planned appointments

Write the dates of your patient’s scheduled visits, or the pattern, such as “physical and occupational therapy three times a week”. Time the employee takes to bring your patient to these is protected, so listing them helps.

Item 8: referrals to other clinicians

If you referred your patient elsewhere, write what for, the start and end dates of that treatment, and how long each visit takes, including recovery. A specialty name such as “oncology” or “psychiatry” can give away the diagnosis, so when it would, I write a treatment schedule instead, such as “medical specialist evaluation and treatment, monthly”.

Item 9: one continuous block of time

If your patient will be incapacitated for one continuous stretch, including treatment and recovery, write a start date and an end date. A best estimate is what is asked. If you truly cannot say yet, give a date when you will reassess and explain it in item 6, because an empty end date reads as “unknown”.

Item 10: time off in episodes

Read this one carefully, because it is worded differently from the WH-380-E. It asks whether it is medically necessary for the employee to be absent from work now and then to care for your patient, for example during flare-ups. Over the next six months, estimate how often the episodes will come (times per day, week or month) and how long each one will last (hours or days). It needs both numbers. “About two to three days a month for falls, illness and unscheduled visits” is a complete answer, and “as needed” is not. A patient can need time in both places, such as dialysis three times a week in item 7 and unpredictable bad days here in item 10. 29 C.F.R. §§ 825.124(c), 825.306(a)(8)

This is where having the caregiver in the room matters most. I ask how often the bad spells have been coming and how long each one needs the employee there, and we settle the numbers together.

Your signature, and no Part C

Sign and date the bottom of page 4 with the same name you printed in your contact block. Notice what is not there. On the WH-380-E, Part C asks which core part of the job your patient cannot do. This form has no Part C and no job question at all, so I do not volunteer an opinion about whether the employee can do their job. The employee signs their own line at the end of Section II, and a form where the clinician signed that line will not be accepted.

Who carries it out of the room

The form says to return it to the patient, never to the Department of Labor. On the WH-380-E that is simple, because your patient carries their own information to their own employer. Here the form has to reach the employee’s employer, and the employee is not your patient. Handing it over is a disclosure of your patient’s health information, and “she is his daughter” is not by itself permission. My understanding is that the details depend on your state and your practice’s policy, so check with your privacy officer. What I do is get a signed authorization at the visit from my patient, or from whoever properly speaks for my patient, naming the employee and the employer, and note in the chart what I released and to whom. 29 C.F.R. § 825.307(a); 45 C.F.R. § 164.508

If HR calls you afterwards, they may only confirm that you completed the form or ask what an answer means. They may not ask for more than the form asks, and the call may never come from the employee’s direct supervisor. 29 C.F.R. § 825.307(a)

Why a WH-380-F is not accepted: the usual suspects

1. Section II is blank, or the clinician filled it in or signed the employee’s line.
2. Item 4 names the diagnosis instead of the care your patient needs, or contradicts what the employee checked in Section II.
3. Item 3 says “unknown”, “lifetime” or “indeterminate”.
4. Item 10 has how often but not how long, or the reverse, or says “as needed”.
5. A box is checked in item 5 but the lines under it are empty, or Part B is empty.
6. Your patient’s name is in the “Employee Name” header, or the answers follow the WH-380-E’s numbering and landed on the wrong item.

HR has to tell the employee in writing what is missing and give them at least seven days to fix it, and if the corrected form still falls short the leave can be denied. When only a number changes, in my experience HR will usually accept the correction on the original form, crossed out with a single line, initialed and dated. 29 C.F.R. §§ 825.305(c), 825.313

The longer version

I also wrote a longer walkthrough of this form on my other site, The Physician’s Back Office, with each page of the form shown and every item marked. Read the full WH-380-F walkthrough. For the other FMLA forms a practice sees, see FMLA paperwork for doctors.

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