(a) DOL has developed an optional form (Form WH-380, as revised) for
employees' (or their family members') use in obtaining medical
certification, including second and third opinions, from health care
providers that meets FMLA's certification requirements. (See Appendix B
to these regulations.) This optional form reflects certification
requirements so as to permit the health care provider to furnish
appropriate medical information within his or her knowledge.
(b) Form WH-380, as revised, or another form containing the same
basic information, may be used by the employer; however, no additional
information may be required. In all instances the information on the
form must relate only to the serious health condition for which the
current need for leave exists. The form identifies the health care
provider and type of medical practice (including pertinent
specialization, if any), makes maximum use of checklist entries for ease
in completing the form, and contains required entries for:
(1) A certification as to which part of the definition of ``serious
health condition'' (see Sec. 825.114), if any, applies to the patient's
condition, and the medical facts which support the certification,
including a brief statement as to how the medical facts meet the
criteria of the definition.
(2)(i) The approximate date the serious health condition commenced,
and its probable duration, including the probable duration of the
patient's present incapacity (defined to mean inability to work, attend
school or perform other regular daily activities due
to the serious health condition, treatment therefor, or recovery
therefrom) if different.
(ii) Whether it will be necessary for the employee to take leave
intermittently or to work on a reduced leave schedule basis (i.e., part-
time) as a result of the serious health condition (see Sec. 825.117 and
Sec. 825.203), and if so, the probable duration of such schedule.
(iii) If the condition is pregnancy or a chronic condition within
the meaning of Sec. 825.114(a)(2)(iii), whether the patient is presently
incapacitated and the likely duration and frequency of episodes of
incapacity.
(3)(i)(A) If additional treatments will be required for the
condition, an estimate of the probable number of such treatments.
(B) If the patient's incapacity will be intermittent, or will
require a reduced leave schedule, an estimate of the probable number and
interval between such treatments, actual or estimated dates of treatment
if known, and period required for recovery if any.
(ii) If any of the treatments referred to in subparagraph (i) will
be provided by another provider of health services (e.g., physical
therapist), the nature of the treatments.
(iii) If a regimen of continuing treatment by the patient is
required under the supervision of the health care provider, a general
description of the regimen (see Sec. 825.114(b)).
(4) If medical leave is required for the employee's absence from
work because of the employee's own condition (including absences due to
pregnancy or a chronic condition), whether the employee:
(i) Is unable to perform work of any kind;
(ii) Is unable to perform any one or more of the essential functions
of the employee's position, including a statement of the essential
functions the employee is unable to perform (see Sec. 825.115), based on
either information provided on a statement from the employer of the
essential functions of the position or, if not provided, discussion with
the employee about the employee's job functions; or
(iii) Must be absent from work for treatment.
(5)(i) If leave is required to care for a family member of the
employee with a serious health condition, whether the patient requires
assistance for basic medical or personal needs or safety, or for
transportation; or if not, whether the employee's presence to provide
psychological comfort would be beneficial to the patient or assist in
the patient's recovery. The employee is required to indicate on the form
the care he or she will provide and an estimate of the time period.
(ii) If the employee's family member will need care only
intermittently or on a reduced leave schedule basis (i.e., part-time),
the probable duration of the need.
(c) If the employer's sick or medical leave plan requires less
information to be furnished in medical certifications than the
certification requirements of these regulations, and the employee or
employer elects to substitute paid sick, vacation, personal or family
leave for unpaid FMLA leave where authorized (see Sec. 825.207), only
the employer's lesser sick leave certification requirements may be
imposed.
