Certification of Qualifying Exigency
U.S. Department of Labor
For Military Family Leave
Wage and Hour Division
(Family and Medical Leave Act)
OMB Control Number: 1235-0003
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may
require an employee seeking FMLA leave due to a qualifying exigency to submit a certification. Please complete Section I
before giving this form to your employee. Your response is voluntary, and while you are not required to use this form, you
may not ask the employee to provide more information than allowed under the FMLA regulations, 29 CFR 825.309.
Employer name: ____________________________________________________________________________________
Contact Information: _________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II fully and completely. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due
to a qualifying exigency. Several questions in this section seek a response as to the frequency or duration of the qualifying
exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine
FMLA coverage. Your response is required to obtain a benefit. 29 CFR 825.310. While you are not required to provide
this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at
least 15 calendar days to return this form to your employer.
Your Name: _______________________________________________________________________________________
Name of military member on covered active duty or call to covered active duty status:
Relationship of military member to you: ___________________________________________________________
Period of military member’s covered active duty: __________________________________________________________
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written
documentation confirming a military member’s covered active duty or call to covered active duty status. Please check one
of the following and attach the indicated document to support that the military member is on covered active duty or call to
covered active duty status.
A copy of the military member’s covered active duty orders is attached.
Other documentation from the military certifying that the military member is on covered active duty (or has been
notified of an impending call to covered active duty) is attached.
I have previously provided my employer with sufficient written documentation confirming the military member’s
covered active duty or call to covered active duty status.
CONTINUED ON NEXT PAGE
WH-384 R evised February 2013