____________________________________________________________________________________________________________________________________________________________________________________________________________

Notice to the EMPLOYER INSTRUCTIONS to the EMPLOYER:

(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

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

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

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.

Certification for Serious Injury or Illness

SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom

(This section must be completed first before any of the below sections can be

Name and Address of Employer (this is the employer of the employee requesting leave to care for covered

____________________________________________________________________________________________

Name of Employee Requesting Leave to Care for Covered Servicemember:

____________________________________________________________________________________________

Name of Covered Servicemember (for whom employee is requesting leave to care):

____________________________________________________________________________________________

Relationship of Employee to Covered Servicemember Requesting Leave to Care:

Part B: COVERED SERVICEMEMBER INFORMATION

Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or

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:

_________________________________________

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

____________________________________________________________________________________________

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. If you are unable to make certain of the

military-related determinations contained below in Part B, you are permitted to rely upon determinations

from an authorized DOD representative (such as a DOD recovery care coordinator).

Section I above has been completed before completing this section.) Please be sure to sign the form on the last

Part A: HEALTH CARE PROVIDER INFORMATION

Health Care Provider’s Name and Business Address:

____________________________________________________________________________________________

Type of Practice/Medical Specialty: _______________________________________________________________

Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD

TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized

private health care provider: _____________________________________________________________________

) ______________ Email: ___________________________________

(1) Covered Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):

– Illness/Injury is of such a severity that life is imminently

endangered. Family members are requested at bedside immediately. (Please note this is an internal DOD

casualty assistance designation used by DOD healthcare providers.)

– Illness/injury is of such severity that there is cause for immediate concern,

but there is no imminent danger to life. Family members are requested at bedside. (Please note this is an

internal DOD casualty assistance designation used by DOD healthcare providers.)

– a serious injury or illness that may render the servicemember medically unfit to

perform the duties of the member’s office, grade, rank, or rating.

(Note to Employee: If this box is checked, you may still be eligible to take

leave to care for a covered family member with a “serious health condition” under § 825.113 of the FMLA.

If such leave is requested, you may be required to complete DOL FORM WH-380 or an employer-provided

(2) Was the condition for which the Covered Service member is being treated incurred in line of duty on active

(3) Approximate date condition commenced: _______________________________________________

(4) Probable duration of condition and/or need for care: ______________________________________

(5) Is the covered servicemember undergoing medical treatment, recuperation, or therapy? ____Yes ___No. If

yes, please describe medical treatment, recuperation or therapy:

_________________________________________________________________________________________

PART C: COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER

(1) Will the covered servicemember need care for a single continuous period of time, including any time for

If yes, estimate the beginning and ending dates for this period of time: ________________________________

(2) Will the covered servicemember require periodic follow-up treatment appointments?

___ Yes ___ No If yes, estimate the treatment schedule: __________________________________________

(3) Is there a medical necessity for the covered servicemember to have periodic care for these follow-up treatment

(4) Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled

follow-up treatment appointments (e.g., episodic flare-ups of medical condition)? ____Yes ____No If yes,

please estimate the frequency and duration of the periodic care:

_________________________________________________________________________________________

Signature of Health Care Provider: ________________________________ Date: _______________________

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, in accordance with 29 U.S.C.

§ 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB

control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of

information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this

collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S.

Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, DC 20210.

TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE PATIENT.