Form Wh-384 - Certification Of Qualifying Exigency For Military Family Leave (Family And Medical Leave Act) Page 2
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3PART A: QUALIFYING REASON FOR LEAVE
1.
Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you
are requesting leave):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2.
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes
any available written documentation which supports the need for leave; such documentation may include a copy of
a meeting announcement for informational briefings sponsored by the military; a document confirming the military
member’s Rest and Recuperation leave; a document confirming an appointment with a third party, such as a
counselor or school official, or staff at a care facility; or a copy of a bill for services for the handling of legal or
financial affairs. Available written documentation supporting this request for leave is attached.
Yes
No
None Available
PART B: AMOUNT OF LEAVE NEEDED
1.
Approximate date exigency commenced: __________________________________________________________
Probable duration of exigency: __________________________________________________________________
2.
Will you need to be absent from work for a single continuous period of time due to the qualifying exigency?
Yes
No
If so, estimate the beginning and ending dates for the period of absence:
___________________________________________________________________________________________
3.
Will you need to be absent from work periodically to address this qualifying exigency?
Yes
No
Estimate schedule of leave, including the dates of any scheduled meetings or appointments:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time
(i.e. , 1 deployment-related meeting every month lasting 4 hours):
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours ___ day(s) per event.
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CONTINUED ON NEXT PAGE
WH-384 R evised February 2013
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