Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (Family And Medical Leave Act)

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Notice of Eligibility and Rights &
U.S. Department of Labor
Wage and Hour Division
(Family and Medical Leave Act)
____________________________________________________________________________ ____________________________________________
OMB Control Number: 1235-0003
Expires: 4/30/2015
____________________________________________________________________________ ____________________________________________
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).
_ _______________________________________
FROM: _________ _______________________________
Employer Representative
DATE: _________ _______________________________
On _____________________, you informed us that you needed leave beginning on _______________________ for:
_____ The birth of a child, or placement of a child with you for adoption or foster care;
_____ Your own serious health condition;
_____ Because you are needed to care for your ____ spouse; _____child; ______ parent due to his/her serious health condition.
_____ Because of a qualifying exigency arising out of the fact that your ____ spouse; _____son or daughter; ______ parent is on covered
active duty or call to covered active duty status with the Armed Forces.
_____ Because you are the ____ spouse; _____son or daughter; ______ parent; _______ next of kin of a covered servicemember with a
serious injury or illness.
This Notice is to inform you that you:
_____ Are eligible for FMLA leave (See Part B below for Rights and Responsibilities)
_____ Are not eligible for FMLA leave, because (only one reason need be checked, although you may not be eligible for other reasons):
_____ You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave, you will
have worked approximately ___ months towards this requirement.
You have not met the FMLA’s hours of service requirement.
You do not work and/or report to a site with 50 or more employees within 75-miles.
If you have any questions, contact
or view the
FMLA poster located in
As explained in Part A, you meet the eligibilit y requirements for taking F MLA 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.
Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to support your
request ____is/____ is not enclosed.
Sufficient documentation to establish the required relationship between you and your family member.
Other information needed (such as documentation for military family leave): ________________________________________________________
No additional information requested
Page 1
Form WH-381 Revised February 2013


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