Form Wh-381 - Employer Response To Employee Request For Family Or Medical Leave

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Employer Response to Employee
U.S. Department of Labor
Request for Family or Medical Leave
Employment Standards Administration
Wage and Hour Division
(Optional Use Form -- See 29 CFR § 825.301)
(Family and Medical Leave Act of 1993)
OMB No: 1215-0181
Date:
Expires:
09-30-20104
To:
(Employee’s Name)
From:
(Name of Appropriate Employer Representative)
Subject: REQUEST FOR FAMILY/MEDICAL LEAVE
On
, you notified us of your need to take family/medical leave due to:
(Date)
o
The birth of a child, or the placement of a child with you for adoption or foster care; or
o
A serious health condition that makes you unable to perform the essential functions for your job: or
o
o
o
o
A serious health condition affecting your
spouse,
child,
parent, for which you are needed to
provide care.
and that you expect
You notified us that you need this leave beginning on
(Date)
.
leave to continue until on or about
(Date)
Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month
period for the reasons listed above. Also, your health benefits must be maintained during any period of unpaid
leave under the same conditions as if you continued to work, and you must be reinstated to the same or an
equivalent job with the same pay, benefits, and terms and conditions of employment on your return from leave. If
you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset
of a serious health condition which would entitle you to FMLA leave; or (2) other circumstances beyond your
control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during
your FMLA leave.
This is to inform you that:
(check appropriate boxes; explain where indicated)
o
o
1. You are
eligible
not eligible for leave under the FMLA.
o
o
2. The requested leave
will
will not be counted against your annual FMLA leave entitlement.
o
o
3. You
will
will not be required to furnish medical certification of a serious health condition. If required,
you must furnish certification by
(must be at least 15 days
(insert date)
after you are notified of this requirement), or we may delay the commencement of your leave until the certification
is submitted.
o
o
4. You may elect to substitute accrued paid leave for unpaid FMLA leave. We
will
will not require that
you substitute accrued paid leave for unpaid FMLA leave. If paid leave will be used, the following conditions will
apply:
(Explain)
Form WH-381 1 9
Rev. June 1997

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