Form Wh-384385 - Employee Rights And Responsibilities Under The Family And Medical Leave Act Page 9
Download a blank fillable Form Wh-384385 - Employee Rights And Responsibilities Under The Family And Medical Leave Act 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-384385 - Employee Rights And Responsibilities Under The Family And Medical Leave Act 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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16SECTION I: For Completion by the EMPLOYEE and/or the CURRENT 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 the current
servicemember):
Human Resources Department, Jefferson County Courthouse, 1225 Pearl Street, Suite 201, Beaumont, Texas 77701.
____________________________________________________________________________________________
Name of Employee Requesting Leave to Care for the Current Servicemember:
____________________________________________________________________________________________
First
Middle
Last
Name of the Current Servicemember (for whom employee is requesting leave to care):
____________________________________________________________________________________________
First
Middle
Last
Relationship of Employee to the Current Servicemember:
Spouse
Parent
Son
Daughter
Next of Kin
Part B: SERVICEMEMBER INFORMATION
(1)
Is the Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves?
Yes
No
If yes, please provide the servicemember’s military branch, rank and unit currently assigned to:
_______________________________________________________________________________________
Is the 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 Servicemember on the Temporary Disability Retired List (TDRL)?
Yes
No
Part C: CARE TO BE PROVIDED TO THE SERVICEMEMBER
Describe the Care to Be Provided to the Current Servicemember and an Estimate of the Leave Needed to Provide the
Care:
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 2
Form WH-385 Revised May 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (family And Medical Leave Act)
Business
Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act - State Of Connecticut Human Resources
Business
Form 1003 - Notice Of Eligibility And Rights & Responsibilities (family And Medical Leave Act)
Business
Form Wh-380-e - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act)
Business
Form Wh-380-e - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act)
Business
Form Wh-380-e - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act)
Business
Form Wh-385 - Certification For Serious Injury Or Illness Of A Current Servicemember For Military Family Leave (family And Medical Leave Act)
Business
Form Wh-384 - Certification Of Qualifying Exigency For Military Family Leave (family And Medical Leave Act)
Business
Related Categories
Parent category: Legal