Form Wh-381 - Notice Of Eligibility And Rights And Responsibilities (Family And Medical Leave Act)
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2Notice of Eligibility and Rights &
U.S. Department of Labor
Wage and Hour Division
Responsibilities
(Family and Medical Leave Act)
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OMB Control Number: 1235-0003
Expires: 4/30/2015
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____________________________________________________________________________ ____________________________________________
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______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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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 ELIGIBILITY]
TO:
_ _______________________________________
Employee
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
[PART B-RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE]
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.
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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.
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Sufficient documentation to establish the required relationship between you and your family member.
____
Other information needed (such as documentation for military family leave): ________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
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No additional information requested
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CONTINUED ON NEXT PAGE
Form WH-381 Revised February 2013
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