Form Wh-381 - Notice Of Eligibility And Rights & Responsibilities

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Notice of Eligibility and Rights &
In general, to be eligible an employee must have worked for an employer for at least 12 months, have worked at least 1,250 hours 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, which must be provided within five
business days of the employer being notified of the need for FMLA leave.
To (Employee Name):
From (Employer Representative):
, you informed us that you needed leave beginning on,
, we were notified that you may qualify for FMLA leave for:
Birth of my child; to care for my newborn child
Placement of a child with me for
foster care
Leave to care for family member with a serious health condition. Relationship:
Your own serious health condition.
Qualifying exigency because a family member is on covered active duty or has been notified of an impending call or order to
covered active duty in the armed forces. Relationship:
I am a
next of kin caring for a covered military servicemember or veteran recovering from an
injury or illness suffered while on active duty in the armed forces, that existed before the beginning of the member's active duty
and was aggravated by service, or that manifested itself before or after the member became a veteran.
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 1,250-hours-worked 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:
Part B - Rights and Responsibilities for take 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 (checked below) to us by
Sufficient certification to support your request for FMLA leave
Sufficient documentation to establish the required relationship between you and your family member.
Other Information needed:
No additional information requested.
NOTE: A form that sets forth the information necessary to support your request is enclosed. If sufficient information is not
provided in a timely manner, your leave may be denied.
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Revised: August


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