Notice of Eligibility & Rights and Responsibilities 
 
 
under the Family and Medical Leave Act 
 

 

U.S. Department of Labor 
 
Wage and Hour Division 
 

 

 

DO NOT SEND TO THE DEPARTMENT OF LABOR. 
 
OMB Control Number: 1235-0003 
 
 
Expires: 6/30/2023 
PROVIDE TO EMPLOYEE. 
 
In general, to be eligible to take leave under the Family and Medical Leave Act (FMLA), 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 is optional, a fully completed Form WH-
381 provides employees with the information required by 29 C.F.R. §§ 825.300(b), (c) which must be provided within five 
 
business days of the employee notifying the employer of the need for FMLA leave. Information about the FMLA may be 
 
found on the WHD website at www.dol.gov/agencies/whd/fmla. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date: ___________________________ (mm/dd/yyyy) 

 

     

From: ___________________________________ (Employer) To: ______________________________________ (Employee) 
 

On __________________ (mm/dd/yyyy), we learned that you need leave (beginning on) _____________________ (mm/dd/yyyy) 
 
for one of the following reasons: (Select as appropriate) 
 

 

 

 

 

 The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or 

 

 

newly-placed child 

 Your own serious health condition 

 You are needed to care for your family member due to a serious health condition. Your family member is your: 

 

 

 

 

 Spouse 
 

 Parent 
 
 

 Child under age 18   Child 18 years or older and incapable of self-
 
 
care because of a mental or physical disability 
 
 

   

 

 

 

 

 

 A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of 
 

 
an impending call or order to covered active duty status. Your family member on covered active duty is your: 

 

 

 

 

 

 

 

 Spouse 

 Parent 

 Child of any age 

 

 You are needed to care for your family member who is a covered servicemember with a serious injury or illness. You 

 

 

 

 

 

are the servicemember’s: 

 Spouse 

 Parent 

 Child 

 Next of kin 

 

 

Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in 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 to care for an individual who assumed the obligations of a parent 
 
to the employee when the employee was a child. An employee may also take FMLA leave to care for a child for whom the employee 
 
has assumed the obligations of a parent. No legal or biological relationship is necessary. 
   

 

 

 

 

 

 

 

 

 

 

 

 

This Notice is to inform you that you are: 

 

 

 

SECTION I – NOTICE OF ELIGIBILITY 
 

 

 Eligible for FMLA leave. (See Section II for any Additional Information Needed and Section III for information on your Rights 

 

 

 

 

 

 

and Responsibilities.) 

 Not eligible for FMLA leave because: (Only one reason need be checked) 

 

 

 

 

 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: __________ towards this requirement. 
 

(months) 
 

 You have not met the FMLA’s 1,250 hours of service requirement. As of the first date of requested leave, you 
 

 

 

 

 

will have worked approximately: _______________towards this requirement. 

 

(hours of service) 
 

Page 1 of 4 
 

Form WH-381, Revised June 2020 
 

 

 
Employee Name: ____________________________________________________________________________________________ 

 You are an airline flight crew employee and you have not met the special hours of service eligibility requirements 
for airline flight crew employees as of the first date of requested leave (i.e., worked or been paid for at least 60% 
of your applicable monthly guarantee, and worked or been paid for at least 504 duty hours.) 

 

 

 

 

 

 

 

 

 

 

 You do not work at and/or report to a site with 50 or more employees within 75-miles as of the date of your 

 

 

 

 

 

request. 

If you have any questions, please contact: ________________________________________ (Name of employer representative) 
 

 

 

at _________________________________________________________________________________________________ (Contact information). 
 

 

SECTION II – ADDITIONAL INFORMATION NEEDED 
 

 

 
 

As explained in Section I, you  meet the eligibility requirements for taking FMLA leave. Please review the information 
 
below to determine if additional information is needed in order for us to determine whether your absence qualifies as FMLA 
 
leave. Once we obtain any additional information specified below we will inform you, within 5 business days, whether 
 
your leave will be designated as FMLA leave and count towards the FMLA leave you have available. If complete and 
sufficient information is not provided in a timely manner, your leave may be denied. 
   

 

 

 

 

 

 

 

 

(Select as appropriate) 
 

 No additional information requested. If no additional information requested, go to Section III. 

 

 We request that the leave be supported by a certification, as identified below. 

 

 Health Care Provider for the Employee 
 
 Qualifying Exigency 
 

 
 

 

 

 Health Care Provider for the Employee’s Family Member 
 Serious Illness or Injury (Military Caregiver Leave) 

 

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

 

 

 

 

 

   

Selected certification form is  attached /  not attached. 

 

 

 
 

We request that you provide reasonable documentation or a statement to establish the relationship between you and 
 
your family member, including in loco parentis relationships (as explained on page one). The information requested 
 
must be returned to us by ____________________ (mm/dd/yyyy). You may choose to provide a simple statement of the 
relationship or  provide documentation such as  a child’s birth certificate, a court document, or documents regarding 
 
foster care or adoption-related activities. Official documents submitted for this purpose will be returned to you after 
 
examination. 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Other information needed (e.g. documentation for military family leave): ________________________________. 

 

The information requested must be returned to us by _____________________ (mm/dd/yyyy). 

 

If you have any questions, please contact: ________________________________________ (Name of employer representative) 
 

 

at __________________________________________________________________________ (Contact information). 

 

SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES 
 

Part A: FMLA Leave Entitlement 
 

 

 

 

You have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family and 
medical reasons, including up to 12 weeks of unpaid leave in a 12-month period for the birth of a child or placement of a 
 
 
child for adoption or foster care, for leave related to your own or a family member’s serious health condition, or for certain 
 
 
qualifying exigencies related to the deployment of a military member to covered active duty. You also have a right 
   

 
 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 4 
 
 

 

Form WH-381, Revised June 2020 
 

 

 

 
Employee Name: ____________________________________________________________________________________________ 

 
under the FMLA to take up to 26 weeks of unpaid, job-protected FMLA leave in a single 12-month period to care for a 
 
 
covered servicemember with a serious injury or illness (Military Caregiver Leave). 
   

 

 

 

 

The 12-month period for FMLA leave is calculated as: (Select as appropriate) 
 

 

 The calendar year (January 1st - December 31st) 
 

   

 

 

 

 

 A fixed leave year based on _____________________________________________________________ 
   

 

   
                                                                         

(e.g., a fiscal year beginning on July 1 and ending on June 30) 
 

 

 The 12-month period measured forward from the date of your first FMLA leave usage. 
 

   

 

 

 

 

 

   

 A “rolling” 12-month period measured backward from the date of any FMLA leave usage. (Each time an employee 
 
takes FMLA leave, the remaining leave is the balance of the 12 weeks not used during the 12 months immediately before 
 
 
the FMLA leave is to start.) 
 
 

 

 

 

 

If applicable, the single 12-month period for Military Caregiver Leave started on ______________________ (mm/dd/yyyy). 
   
 
You ( are /  are not) considered a key employee as defined under the FMLA. Your FMLA leave cannot be denied for 
 
this  reason;  however,  we  may  not  restore  you  to  employment  following  FMLA  leave  if  such  restoration  will  cause 
 
 
substantial and grievous economic injury to us. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

We ( have /  have not)  determined that restoring you to employment at the conclusion of FMLA leave will cause 
 
substantial and grievous economic harm to us. Additional information will be provided separately concerning your status 
 
as key employee and restoration. 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part B: Substitution of Paid Leave – When Paid Leave is Used at the Same Time as FMLA Leave 
   
You have a right under the FMLA to request that your accrued paid leave be substituted for your FMLA leave. This means 
 
that you can request that your accrued paid leave run concurrently with some or all of your unpaid FMLA leave, provided 
 
you meet any applicable requirements of our leave policy. Concurrent leave use means the absence will count against both 
 
the designated paid leave and unpaid FMLA leave at the same time. If you do not meet the requirements for taking paid 
leave, you remain entitled to take available unpaid FMLA leave in the applicable 12-month period. Even if  you do not 
 
request it, the FMLA allows us to require you to use your available sick, vacation, or other paid leave during your FMLA 
 
absence. 
   

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
(Check all that apply) 
 
 

 

 Some or all of your FMLA leave will not be paid. Any unpaid FMLA leave taken will be designated as FMLA 
 
leave and counted against the amount of FMLA leave you have available to use in the applicable 12-month period. 
 

 
 

 

 

 

 

 

 

 

 

 You have requested to use some or all of your available paid leave (e.g., sick, vacation, PTO)  during your FMLA 
 
leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of 
 
FMLA leave you have available to use in the applicable 12-month period. 
 

 

 

 

 

 

 

 

 

 

 

 

 We are requiring you to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA 
 
leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of 
 
FMLA leave you have available to use in the applicable 12-month period. 
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Other: (e.g., short- or long-term disability, workers’ compensation, state medical leave law, etc.)_________________________ 
 
Any time taken for this reason will also be designated as FMLA leave and counted against the amount of 
 
FMLA leave you have available to use in the applicable 12-month period. 
 

 

 

 

The applicable conditions for use of paid leave include: ____________________________________________________. 
 
 
   
For more information about conditions applicable to sick/vacation/other paid leave usage please refer to _____________ 

 

 

 

 
__________________________________________ available at: ____________________________________________. 

 

 
Page 3 of 4 
 
 

 

 

Form WH-381, Revised June 2020 
 

 

 

 

 

 

 

 

   

 

     

 

 

     

 

 

 

 

 

 

 

 

 

 

 

 

   

   

 
Employee Name: ____________________________________________________________________________________________ 
 
Part C: Maintain Health Benefits 
Your health benefits must be maintained during any period of FMLA leave under the same conditions as if you continued 
 
 
to work. During any paid portion of FMLA leave, your share of any premiums will be paid by the method normally used 
 
during any paid leave. During any unpaid portion of FMLA leave, you must continue to make any normal contributions to 
 
the cost of the health insurance premiums. To make arrangements to continue to make your share of the premium payments 
 
on  your  health  insurance  while  you  are  on  any  unpaid  FMLA  leave,  contact  ____________________________  at 
_____________________________________. 
 
   
You have a minimum grace period of ( 30-days or  _____________ indicate longer period, if applicable) in which to 
make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify 
you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share 
of the premiums during FMLA leave, and recover these payments from you upon your return to work. 
 
You may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA 
 
leave if you do not return to work following unpaid FMLA leave for a reason other than: the continuation, recurrence, or 
 
onset of your or your family member’s serious health condition which would entitle you to FMLA leave; or the continuation, 
recurrence, or onset of a covered servicemember’ s serious injury or illness which would entitle you to FMLA leave; or 
other circumstances beyond your control. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

Part D: Other Employee Benefits 
 
Upon your return from FMLA leave, your other employee benefits, such as pensions or life insurance, must be resumed in 
the same manner and at the same levels as provided when your FMLA leave began. To make arrangements to continue 
 
your employee benefits while you are on FMLA leave, contact _______________________________________________ 
 
at _________________________________________________. 
 

 

 

 

 

 

 

 

 

 

 

Part E: Return-to-Work Requirements 
 
You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment 
 
on your return from FMLA-protected leave. An equivalent position is one that is virtually identical to your former position 
 
in terms of pay, benefits, and working conditions. At the end of your FMLA leave, all benefits must also be resumed in the 
 
same manner and at the same level provided when the leave began. You do not have return-to-work rights under the FMLA 
 
if you need leave beyond the amount of FMLA leave you have available to use. 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part F: Other Requirements While on FMLA Leave 
 

 

 

While on leave you ( will be /  will not be) required to furnish us with periodic reports of your status and intent to 
return to work every ________________________________________________________________________________. 
 

(Indicate interval of periodic reports, as appropriate for the FMLA leave situation). 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
If the circumstances of your leave change and you are able to return to work earlier than expected, 
 
you will be required to notify us at least two workdays prior to the date you intend to report for work. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

   
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT 
It  is  mandatory  for  employers  to  provide  employees  with  notice  of  their  eligibility  for  FMLA  protection  and  their  rights  and 
 
responsibilities. 29 U.S.C. § 2617; 29 C.F.R. § 825.300(b), (c). 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 10 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 LABOR. EMPLOYEE INFORMATION. 

 

 

 
Page 4 of 4 
 
 

 

 

Form WH-381, Revised June 2020