Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (Family And Medical Leave) - U.s. Department Of Labor - 2013

Download a blank fillable Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (Family And Medical Leave) - U.s. Department Of Labor - 2013 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (Family And Medical Leave) - U.s. Department Of Labor - 2013 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Notice of Eligibility and Rights & 
U.S. Department of Labor
Wage and Hour Division
Responsibilities 
 
(Family and Medical Leave) 
_
 
 
OMB Control Number: 1235-0003
Expires: 2/28/2015
 
 
In general, to be eligible an employee must have worked for an employer for at least 12 months, meet the hours of service requirement 
in the 12 months preceding the leave, and work at a site with at least 50 employees within 75 miles. While use of this form by 
employers is optional, a fully completed Form WH‐381 provides employees with the information required by 29 C.F.R. § 825.300(b), 
which must be provided within five business days of the employee notifying the employer of the need for FMLA leave. Part B provides 
employees with information regarding their rights and responsibilities for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).  
[Part A – NOTICE OF ELIGIBILTY]
TO:
Employee 
Paige Cash
FROM:
Employer Representative 
DATE
 
On ___________________ you informed us that you need leave beginning on ________________ for:
Scheduled date of adoption or placement
This notice is to inform you that you:
or
Paige Cash
If you have any questions, contact___________________________________________________________ or view the
770-449-5300
FMLA Poster located in the break room area.
[PART B-RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE ]
As explained in Part A, you meet the eligibility requirements for taking FMLA leave and still have FMLA leave available in
the applicable 12-month period. However, in order for us to determine whether your absence qualifies as FMLA leave,
you must return the following information to us by ___________________________________. (If a certification is
requested, employers must allow at least 15 calendar days from receipt of this notice; additional time may be required in
some circumstances.) If sufficient information is not provided in a timely manner, your leave may be denied.
 
CONTINUED ON NEXT PAGE
Form WH‐381 Revised February 2013
 

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (family And Medical Leave Act) Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (family And Medical Leave Act) Business
Form Wh-381 - Notice Of Eligibility And Rights & Responsibilities Form Wh-381 - Notice Of Eligibility And Rights & Responsibilities Business
Form Ca-16 - Authorization For Examination And/or Treatment - U.s. Department Of Labor Form Ca-16 - Authorization For Examination And/or Treatment - U.s. Department Of Labor Legal
Form Cfn 552-0755 - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act) - Iowa Department Of Administrative Services Form Cfn 552-0755 - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act) - Iowa Department Of Administrative Services Business
Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Legal
Form Hud-51234 - Report On Occupancy For Public And Indian Housing - U.s. Department Of Housing And Urban Development Form Hud-51234 - Report On Occupancy For Public And Indian Housing - U.s. Department Of Housing And Urban Development Legal
Form Hud 50071 - Certification Of Payments To Influence Federal Transactions - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development Form Hud 50071 - Certification Of Payments To Influence Federal Transactions - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development Legal
Form Hud-50080-hei - Payment Voucher - Hope - Elderly Independence - Office Of Public And Indian Housing - U.s. Department Of Housing Omb Approval No. 2577-0166 (exp. 9/30/2010) And Urban Development Form Hud-50080-hei - Payment Voucher - Hope - Elderly Independence - Office Of Public And Indian Housing - U.s. Department Of Housing Omb Approval No. 2577-0166 (exp. 9/30/2010) And Urban Development Legal
Form Hud-50080-ihbg - Payment Voucher - Indian Housing Block Grant - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development Form Hud-50080-ihbg - Payment Voucher - Indian Housing Block Grant - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development Legal
Form Hud-50080-vrp - Payment Voucher - Vacancy Reduction Program - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development Form Hud-50080-vrp - Payment Voucher - Vacancy Reduction Program - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development Legal

Related Categories

Parent category: Business
Download
Go
Page of 2