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Certification For Serious Injury Or Illness Of Covered Servicemember WH-385 - Official Federal Forms
| Certification For Serious Injury Or Illness Of Covered Servicemember Form. This is a national form and can be used in US Dept Of Labor . |
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Certification for Serious Injury or Illness of Covered Servicemember - for Military Family Leave (Family and Medical Leave Act) U.S. Department of Labor Wage and Hour Division ____________________________________________________________________________________________________________________________________________________________________________________________________________ Notice to the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a serious injury or illness of a covered servicemember to submit a certification providing sufficient facts to support the request for leave. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees or employees' family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies. SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom the Employee Is Requesting Leave INSTRUCTIONS to the EMPLOYEE or COVERED SERVICEMEMBER: Please complete Section I before having Section II completed. The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a serious injury or illness of a covered servicemember. If requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to do so may result in a denial of an employee's FMLA request. 29 C.F.R. § 825.310(f). The employer must give an employee at least 15 calendar days to return this form to the employer. SECTION II: For Completion by a UNITED STATES DEPARTMENT OF DEFENSE ("DOD") HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of Veterans Affairs ("VA") health care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed on Page 2 has requested leave under the FMLA to care for a family member who is a member of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness. For purposes of FMLA leave, a serious injury or illness is one that was incurred in the line of duty on active duty that may render the servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating. A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember's serious injury or illness includes written documentation confirming that the covered servicemember's injury or illness was incurred in the line of duty on active duty and that the covered servicemember is undergoing treatment for such injury or illness by a health care provider listed above. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as "lifetime," "unknown," or "indeterminate" may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. OMB Control Number: 1235-0003 Expires: 2/28/2015 Page 1 CONTINUED ON NEXT PAGE Form WH-385 January 2009 American LegalNet, Inc. www.FormsWorkFlow.com Certification for Serious Injury or Illness of Covered Servicemember - - for Military Family Leave (Family and Medical Leave Act) U.S. Department of Labor Wage and Hour Division SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom the Employee Is Requesting Leave: (This section must be completed first before any of the below sections can be completed by a health care provider.) Part A: EMPLOYEE INFORMATION Name and Address of Employer (this is the employer of the employee requesting leave to care for covered servicemember): ____________________________________________________________________________________________ Name of Employee Requesting Leave to Care for Covered Servicemember: ____________________________________________________________________________________________ First Middle Last Name of Covered Servicemember (for whom employee is requesting leave to care): ____________________________________________________________________________________________ First Middle Last Relationship of Employee to Covered Servicemember Requesting Leave to Care: Spouse Parent Son Daughter Next of Kin Part B: COVERED SERVICEMEMBER INFORMATION (1) Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves? ___Yes ____No If yes, please provide the covered servicemember's military branch, rank and unit currently assigned to: _______________________________________________________________________________________ Is the covered servicemember assigned to a military medical treatment facility as an outpatient or to a unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients (such as a medical hold or warrior transition unit)? ___Yes ___No If yes, please provide the name of the medical treatment facility or unit: _________________________________________ (2) Is the Covered Servicemember on the Temporary Disability Retired List (TDRL)? ____Yes ____No Part C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER Describe the Care to Be Provided to the Covered Servicemember and an Estimate of the Leave Needed to Provide the Care: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Page 2 CONTINUED ON NEXT PAGE Form
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