How to fill out Form WH-380-E (FMLA, employee)

Your contact details

Your printed name, business address, type of practice or specialty, phone, fax and email.

Part A: medical information

Item 1 asks for the approximate date the condition started or will start. Item 2 asks how long it lasted or will last.

Item 3 is a set of boxes. Check every one that applies, because each checked box needs an amount of leave in Part B:

• Inpatient care: an overnight stay in a hospital, hospice or residential care facility, with the dates.
• Incapacity plus treatment: incapacity for more than three consecutive full calendar days, with the dates, the dates the patient was or will be seen, and whether the condition led to continuing treatment such as prescription medication.
• Pregnancy, with the expected delivery date.
• Chronic condition that needs treatment visits at least twice a year.
• Permanent or long term condition that needs continuing supervision.
• Condition that needs multiple treatments.
• None of the above. The form says no more information is needed; go to the signature.

Item 4: other medical facts

If needed, briefly describe other relevant medical facts. The form gives the use of a nebulizer or dialysis as examples.

The form says you may, but do not have to, give symptoms, the diagnosis or the treatment, and that some state or local laws may not allow you to disclose them. Do not include genetic test results or a family history of disease.

Part B: amount of leave needed

Answer each item that matches a box you checked in Part A. The form warns that words like "lifetime" or "unknown" may not be enough, so give a specific estimate.

• Item 5: dates of planned treatment, such as scheduled visits.
• Item 6: referrals to other providers, what the treatment is, its start and end dates, and how long it takes including recovery.
• Item 7: a reduced schedule, with the dates and the hours the employee can work.
• Item 8: a continuous period of incapacity, with its start and end dates.
• Item 9: intermittent absence for flare-ups, with how often episodes are likely over the next six months and how long each one lasts.

Part C: essential job functions

Item 10 asks whether the employee was, is or will be unable to perform one or more essential job functions, and to name at least one.

Use the job functions from Section I if the employer gave them. If not, the form says to use the employee's own description. An employee who is away from work for treatment counts as unable to perform the job during that absence.

Signature

Sign and date the form at the end of Part C.