Certification for Military Family Leave for 
Qualifying Exigency   
under the Family and Medical Leave Act 
________________________________________________________________________________________________________________________ 

U.S. Department of Labor 
Wage and Hour Division 

OMB Control Number: 1235-0003 
DO NOT SEND FORM TO THE DEPARTMENT OF LABOR. 
Expires: 6/30/2023 
RETURN THE COMPLETED FORM TO THE EMPLOYER. 
________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

The  Family  and  Medical  Leave  Act  (FMLA)  provides  that  eligible  employees  may  take  FMLA  leave  for  a  qualifying 
exigency while the employee's spouse, child, or parent (the military member) is on covered active duty or has been notified 
of an impending call or order to covered active duty. The FMLA allows an employer to require an employee seeking FMLA 
leave due to a qualifying exigency to submit a certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the 
employee at least 15 calendar days to provide the certification. 29 C.F.R. § 825.305(b). If the employee fails to provide 
complete and sufficient certification, the employee’s FMLA leave request may be denied. 29 C.F.R. § 825.313. Information 
about the FMLA may be found on the WHD website at http://www.dol.gov/agencies/whd/fmla. 

SECTION I - EMPLOYER 

Either the employee or the employer may complete Section I. While use of this form is optional, it asks the employee for 
the information necessary for a complete and sufficient qualifying exigency certification, which is set out at 29 C.F.R. § 
825.309. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29 
C.F.R. § 825.309.

(1)

Employee name: ________________________________________________________________________

First 

Middle 

Last 

(2)

(3)

Employer name: __________________________________________ Date: _____________________ (mm/dd/yyyy)

  (List date certification requested) 

This certification must be returned by_____________________________________________________________ (mm/dd/yyyy).
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s diligent, good faith efforts.)

SECTION II - EMPLOYEE 

Please complete all Parts of Section II and sign the form before returning it to your employer. The FMLA allows 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. If requested by your employer, your response is required to obtain the benefits and protections of the 
FMLA. 29 C.F.R. § 825.309. Failure to provide a complete and sufficient certification may result in a denial of your FMLA 
leave request. 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. 
You are responsible for making sure the certification is provided to your employer within the time frame requested, 
which must be at least 15 calendar days. 29 C.F.R. § 825.313. 

(1)

Provide the name of the military member on covered active duty or call to covered active duty status:

__________________________________________________________________________________________

First 

Middle 

Last 

(2)  Select your relationship of the military member. The military member is your:

 Spouse

 Parent

 Child, of any age

Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common 
law marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which a person 
assumes the obligations of a parent to a child. An employee may take FMLA leave for a qualifying exigency related a military 
member who assumed the obligations of a parent to the employee when the employee was a child. An employee may also take 
FMLA leave for a qualifying exigency related a military member for whom the employee has assumed the obligations of a 
parent. No legal or biological relationship is necessary. 

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Form WH-384, Revised June 2020 

  Employee Name: ___________________________________________________________________________________________ 

PART A: COVERED ACTIVE DUTY STATUS 

Covered active duty or call to covered active duty in the case of a member of the Regular Armed Forces means duty during 
the deployment of the member with the Armed Forces to a foreign country. Covered active duty or call to covered active 
duty in the case of a member of the Reserve components means duty during the deployment of the member with the Armed 
Forces to a foreign country under a Federal call or order to active duty in support of a contingency operation pursuant to: 
Section 688 of Title 10 of the United States Code; Section 12301(a) of Title 10 of the United States Code; Section 12302 
of Title 10 of the United States Code; Section 12304 of Title 10 of the United States Code; Section 12305 of Title 10 of 
the United States Code; Section 12406 of Title 10 of the United States Code; chapter 15 of Title 10 of the United States 
Code; or, any other provision of law during a war or during a national emergency declared by the President or Congress 
so long as it is in support of a contingency operation. 10 U.S.C. § 101(a)(13)(B).   

An  employer  may  require  the  employee  to  provide  a  copy  of  the  military  member's  active  duty  orders  or  other 
documentation issued by the military which indicates that the military member is on covered active duty or call to covered 
active duty status, and the dates of the military member's covered active duty service. This information need only be 
provided  to  the  employer  once,  unless  additional  leave  is  needed  for  a  different  military  member  or  different 
deployment. 

(3)

(4)

Provide the dates of the military member’s covered active duty service: __________________________________

Please check one of the following and attach the indicated written 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

 Other documentation from the military indicating that the military member is on covered active duty or has
been notified of an impending call to covered active duty, such as official military correspondence from the
military member’s chain of command

 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

PART B: APPROPRIATE FACTS 

Under  the  FMLA,  leave  can  be  taken  for  a  number  of  qualifying  exigencies.  29  C.F.R.  §  825.126(b).  Complete  and 
sufficient  certification  to  support  a  request  for  FMLA  leave  due  to  a  qualifying  exigency  includes  available  written 
documentation which supports the need for leave such as a copy of a meeting announcement for informational briefings 
sponsored  by  the  military,  a  document  confirming  the  military  member’s  Rest  and  Recuperation  leave,  or  other 
documentation issued by the military which indicates that the military member has been granted Rest and Recuperation 
leave, or a document confirming an appointment with a third party (e.g., a counselor or school official, or staff at a care 
facility, a copy of a bill for services for the handling of legal or financial affairs). Please provide appropriate facts related 
to the particular qualifying exigency to support the FMLA leave request, including information on the type of qualifying 
exigency and any available written documentation of the exigency event. 

(5)

Select the appropriate Qualifying Exigency Category and, if needed, provide additional information related to
the event:

 Short notice deployment (i.e., deployment within seven or fewer days of notice)

 Military events and related activities (e.g., official ceremonies or events, or family support and assistance programs):

_________________________________________________________________________________________________

 Childcare related activities for the child of the military member (e.g., arranging for alternative childcare):

____________________________________________________________________________________________________________

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Form WH-384, Revised June 2020 

  Employee Name: ___________________________________________________________________________________________ 

 Care for the military member’s parent (e.g., admitting or transferring the parent to a new care facility):

____________________________________________________________________________________________________________

 Financial and legal arrangements related to the deployment (e.g., obtaining military identification cards)

 Counseling related to the deployment (i.e., counseling provided by someone other than a health care provider)

 Military member’s short-term, temporary Rest and Recuperation leave (R&R) (leave for this reason is limited

to 15 calendar days for each instance of R&R)

 Post deployment activities (e.g., arrival ceremonies, or reintegration briefings and events):________________________

____________________________________________________________________________________________________________ 

 Any other event that the employee and employer agree is a qualifying exigency: _______________________

____________________________________________________________________________________________________________ 

(6)

Available written documentation supporting this request for leave is ( attached /  not attached /  not
available).

PART C: AMOUNT OF LEAVE NEEDED 

Provide  information  concerning  the  amount  of  leave  that  will  be  needed.  Several  questions  in  this  section  seek  a 
response as to the frequency or duration of the qualifying exigency leave needed. Be as specific as you can; terms such as 
“unknown” or “indeterminate” may not be sufficient to determine FMLA coverage. 

(7)

List the approximate date exigency started or will start: _________________________________________ (mm/dd/yyyy)

(8)

Provide your best estimate of how long the exigency lasted or will last:

From __________________________________ (mm/dd/yyyy) to ____________________________________ (mm/dd/yyyy)

(9) Due to a qualifying exigency, I need to work a reduced schedule. Provide your best estimate of the reduced

schedule you are able to work:

From __________________________________ (mm/dd/yyyy) to ____________________________________ (mm/dd/yyyy)

I am able to work _______________________________________________________________________________

(e.g., 5 hours/day, up to 25 hours a week) 

(10) Due to a qualifying exigency, I will need to be absent from work for a continuous period of time. Provide your

best estimate of the beginning and ending dates for the period of absence:

From _________________________________ (mm/dd/yyyy) to ____________________________________ (mm/dd/yyyy)

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Form WH-384, Revised June 2020 

  Employee Name: ___________________________________________________________________________________________ 

(11) Due to a qualifying exigency, I will need to be absent from work on an intermittent basis (periodically).

Provide your best estimate of the frequency (how often) and duration (how long) of each appointment, meeting, or
leave event, including any travel time.

Over the next 6 months, absences on an intermittent basis are estimated to occur: _______________ times per
( day /  week /  month) and are likely to last approximately _____________ ( hours /  days) per episode.

(12) My leave is due to a qualifying exigency that involves Rest and Recuperation leave (R & R) of the military

member (leave for this reason is limited to 15 calendar days for each instance of R & R leave).

List the dates of the military member’s R &R leave:

From ___________________________________ (mm/dd/yyyy) to ___________________________________ (mm/dd/yyyy)

PART D: THIRD PARTY INFORMATION 

If applicable, please provide information below that may be used by your employer to verify meetings or appointments with 
a third party related to the qualifying exigency. Examples of meetings with third parties include: arranging for childcare or 
parental care, to attend non-medical counseling, to attend meetings with school, childcare or parental care providers, to 
make financial or legal arrangements, to act as the military member’s representative before a federal, state, or local agency 
for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military 
or military service organizations. This information may be used by your employer to verify that the information contained 
on this form is accurate. 

Individual (e.g., name and title) or Entity / Organization: _____________________________________________________ 

Address: __________________________________________________________________________________________ 

Telephone: (___) ________________ Fax: (___) ________________ E-mail: ___________________________________ 

Describe purpose of meeting: __________________________________________________________________________ 

Employee 
Signature _______________________________________________________________ Date ________________ (mm/dd/yyyy) 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT   
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 
2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently 
valid OMB control number. The Department of Labor estimates that it will take an average of 15 minutes for respondents 
to complete this collection of information, including the time for reviewing instructions, searching existing data sources, 
gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any 
comments  regarding  this  burden  estimate  or  any  other  aspect  of  this  collection  information,  including  suggestions  for 
reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 
200 Constitution Avenue, N.W., Washington, D.C. 20210.     

DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF DEPARTMENT OF LABOR. 
RETURN FORM TO THE EMPLOYER.   

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Form WH-384, Revised June 2020