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Form WH-381, Notice of Eligibility, page 1
Moderate · 56/100Form Complexity Index

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What this form asks for

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Form WH-381, Notice of Eligibility & Rights and Responsibilities, is used to inform employees about their eligibility for FMLA leave. It details the rights and responsibilities of employees under the Family and Medical Leave Act, ensuring they understand their entitlements and the necessary steps to take leave.
Fillable fields79
Pages4
Sections26
Tables and lists1
Questions that depend on earlier answers23
Form Complexity IndexModerate, 56/100

The AI checks your answers before you download

15 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

OMB Control Number and Expiration Date Check

Ensures that the OMB Control Number 1235-0003 is accurately present on the form to comply with federal regulations. It also verifies that the expiration date listed is not past the specified date of 6/30/2026, ensuring the form's validity and current applicability. This check is crucial to maintain the legal integrity of the document and to prevent the use of outdated forms.

Timeliness of Completion Check

Confirms that the Notice of Eligibility & Rights and Responsibilities form is completed within the mandated five business days after the employer has been informed of the employee's need for FMLA leave. This validation is essential to adhere to the Department of Labor's requirements and to ensure the employee's rights are recognized in a timely manner. It helps maintain compliance with FMLA regulations.

Current Date Format Check

Verifies that the current date is entered correctly in Section I under 'Date' using the format (mm/dd/yyyy). This check is important to ensure consistency and accuracy in the documentation of when the notice was provided. It also helps in maintaining records that are clear and easily understandable, which is essential for any potential future references or audits.

Employer's Name Entry Check

Checks that the employer's name is correctly entered in Section I under 'From'. This validation ensures that the form is properly addressed and that there is a clear indication of the issuing party. It is vital for establishing the source of the notice and for the proper filing and tracking within the employer's record-keeping systems.

Employee's Name Entry Check

Ensures that the employee's name is accurately entered in Section I under 'To'. This check is crucial for personalizing the notice and confirming that the rights and responsibilities are being communicated to the correct individual. It also serves as a record that the employee in question has been notified regarding their eligibility for FMLA leave.

Date Format Validation

Ensures that the date the employer learned of the employee's need for leave is correctly entered in Section I under 'On'. The AI verifies that the date is provided in the correct format of (mm/dd/yyyy), which is the standard for U.S. date notation. This check is crucial to maintain consistency and avoid any confusion regarding the timeline of events.

And 9 more checks
  • Leave Reason Selection
  • Employee Eligibility Status
  • Ineligibility Details
  • Employer Representative Information
  • Verifies that Section II includes whether additional information is required and if a certification form is attached.
  • Checks the deadline for returning additional information is specified in Section II.
  • Ensures that the method used to calculate the 12-month period for FMLA leave is indicated in Section III Part A.
  • Confirms that any conditions for the use of paid leave are specified and references to the employer's leave policy are provided in Section III Part B.
  • Verifies that instructions for premium payments during unpaid FMLA leave and the grace period are provided in Section III Part C.

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How to Fill Out Form WH-381 Online for Free in 2026

What the AI walks you through.

  1. Visit instafill.ai site and select Form WH-381.
  2. Enter employer and employee details.
  3. Select appropriate leave reasons.
  4. Provide additional information if needed.
  5. Sign and date the form electronically.
  6. Check for accuracy and submit form.

Common Mistakes in Completing Form WH-381

The ones the AI is built to catch.

Incorrect or incomplete date entries in Section I
When completing the Notice of Eligibility & Rights and Responsibilities form, it is essential to provide accurate and complete date entries in Section I. Incorrect dates, such as entering the wrong month, day, or year, can lead to processing delays or even denial of benefits. To avoid this mistake, double-check all date entries before submitting the form. It is also recommended to use the calendar function in your application or software to ensure the correct date is selected.
Failure to select the appropriate reason for leave in Section I
Another common mistake is failing to select the appropriate reason for leave in Section I. This section requires the applicant to indicate the reason for their leave, such as FMLA, Workers' Compensation, or other types of leave. Selecting the incorrect reason can lead to processing delays or denial of benefits. To avoid this mistake, carefully review the options in Section I and select the reason that best applies to your situation. If you are unsure, consult with your employer or HR representative for guidance.
Failure to check the appropriate eligibility status box in Section I or providing insufficient information if not eligible
Failing to check the appropriate eligibility status box in Section I or providing insufficient information if not eligible can result in processing delays or denial of benefits. It is crucial to accurately determine your eligibility status and provide all required information. If you are not eligible for benefits, be sure to indicate this clearly and provide any necessary documentation or information requested in Section II. To avoid this mistake, carefully review the instructions in Section I and consult with your employer or HR representative if you have any questions or concerns about your eligibility status.
Failure to provide the name and contact information of the employer representative in Section I or II
Providing incomplete or incorrect contact information for your employer representative in Section I or II can lead to processing delays or even denial of benefits. It is essential to provide accurate and complete contact information for your employer representative, including their name, phone number, and email address. To avoid this mistake, double-check all contact information before submitting the form and consult with your employer or HR representative if you have any questions or concerns about the information provided.
Failure to return requested additional information on time in Section II
Failing to return requested additional information on time in Section II can result in processing delays or denial of benefits. It is crucial to respond to any requests for additional information promptly and accurately. To avoid this mistake, carefully review all requests for additional information and provide the required documentation or information as soon as possible. If you have any questions or concerns about the request, consult with your employer or HR representative for guidance.
Incorrectly calculating the 12-month period for FMLA leave in Part A
One of the most common errors in completing the Notice of Eligibility & Rights and Responsibilities form involves incorrectly calculating the 12-month period for FMLA leave in Part A. Employees must ensure they use the correct method for calculating their 12-month period, which can be based on the calendar year, a rolling 12-month period, or the 12-month period following the start of their FMLA leave. Failure to accurately calculate this period can result in denial of FMLA leave or complications during the leave process. To avoid this mistake, employees should carefully review the instructions for calculating the 12-month period and consult with their employer or HR representative if they have any questions.
Failing to indicate leave payment status and substitution in Part B
Another common mistake made when completing the Notice of Eligibility & Rights and Responsibilities form is failing to check the boxes indicating whether FMLA leave will be paid or unpaid and if paid leave will be substituted. This information is crucial for both the employee and the employer to understand the financial implications of the leave. Employees should ensure they accurately indicate their leave payment status and whether they will be using paid leave to substitute unpaid FMLA leave. Failure to provide this information can result in misunderstandings and potential financial complications. To avoid this mistake, employees should carefully review the instructions for completing Part B and consult with their employer or HR representative if they have any questions.
Neglecting to provide instructions for premium payments during unpaid FMLA leave in Part C
A third mistake made when completing the Notice of Eligibility & Rights and Responsibilities form is neglecting to provide instructions for premium payments during unpaid FMLA leave in Part C. Employees must provide detailed instructions for how they will pay for their premiums during unpaid FMLA leave to ensure continuation of their health coverage. Failure to provide this information can result in the termination of their health coverage during their leave. To avoid this mistake, employees should carefully review the instructions for completing Part C and consult with their employer or HR representative if they have any questions.
Overlooking return-to-work requirements in Part E
A fourth mistake made when completing the Notice of Eligibility & Rights and Responsibilities form is overlooking return-to-work requirements in Part E. Employees must outline their return-to-work requirements, including the date they expect to return to work and any necessary accommodations, to ensure a smooth transition back to work after their leave. Failure to provide this information can result in delays or complications during the return-to-work process. To avoid this mistake, employees should carefully review the instructions for completing Part E and consult with their employer or HR representative if they have any questions.
Failing to retain the completed form for three years as required
A fifth mistake made when completing the Notice of Eligibility & Rights and Responsibilities form is failing to retain the completed form for the required three years. Employees must keep the completed form for three years from the date of submission to the employer, as required by law. Failure to retain the form can result in potential legal complications. To avoid this mistake, employees should ensure they keep a copy of the completed form in a safe and accessible location for the required three-year period.

Frequently Asked Questions About Form WH-381

 

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What is the Family and Medical Leave Act (FMLA) and who is eligible?
The Family and Medical Leave Act (FMLA) is a federal law that allows eligible employees to take up to 12 weeks of unpaid leave in a 12-month period for specific family and medical reasons. Eligibility requirements include having worked for the employer for at least 12 months and having worked at least 1,250 hours during the previous 12-month period.
How long must an employee have worked for an employer to be eligible for FMLA leave?
To be eligible for FMLA leave, an employee must have worked for the employer for at least 12 months and have worked at least 1,250 hours during the previous 12-month period.
What are the reasons for which an employee can take FMLA leave?
FMLA leave can be taken for the following reasons: the birth of a child and care of the newborn; placement of a child for adoption or foster care; care of an immediate family member (spouse, child, or parent) with a serious health condition; or the employee's own serious health condition.
What information must be provided to the employee within five business days of their request for FMLA leave?
Within five business days of receiving a request for FMLA leave, the employer must provide the employee with written notice of their eligibility for FMLA leave, the amount of leave that will be granted, and any required forms or certifications.
What is the process for requesting FMLA leave?
To request FMLA leave, an employee must provide their employer with at least 30 days' advance notice if the leave is foreseeable. If the leave is not foreseeable, the employee must provide notice as soon as practicable. The employee may be required to provide medical certification supporting the need for leave.
What is the certification process for FMLA leave?
The certification process for Family and Medical Leave Act (FMLA) leave involves the eligible employee providing sufficient medical documentation to their employer to support the need for leave. The employee must typically provide this documentation within 15 calendar days after the employer's request. The employer may also require recertification every 30 days or more frequently if the need for leave continues.
What happens if an employee fails to provide required certification in a timely manner?
If an employee fails to provide the required certification in a timely manner, the employer may deny the request for FMLA leave. The employer may also delay the effective date of the leave until the certification is received. If the employee fails to provide the certification after a reasonable time, the employer may terminate the employee's employment for job abandonment.
What are the employee's rights and responsibilities during FMLA leave?
During FMLA leave, the employee has the right to continue their group health insurance coverage on the same terms as if they were actively employed. The employee is also responsible for providing timely certification and recertification as required by their employer. The employee may also be required to make arrangements for the payment of any premiums due during the leave.
Can an employee use paid leave concurrently with FMLA leave?
Yes, an employee can use paid leave concurrently with FMLA leave. The employee may choose to use paid leave to supplement their unpaid FMLA leave or to cover the first few days of FMLA leave before the unpaid leave begins. The employee should check with their employer to determine the specific policies regarding the use of paid leave and FMLA leave.
What happens to an employee's health benefits during FMLA leave?
During FMLA leave, the employee is entitled to continue their group health insurance coverage on the same terms as if they were actively employed. The employee is responsible for paying any premiums due during the leave. If the employee fails to make timely premium payments, the employer may terminate the coverage.
What happens to an employee's other employee benefits during FMLA leave?
During FMLA leave, an employee is entitled to continued coverage under their employer's group health plan on the same terms as if they had not taken leave. This includes medical, dental, and vision insurance, as well as any other employee benefits provided by the employer. It is important to note that the employee may be required to pay their usual premiums for these benefits while on leave.
What are the return-to-work requirements for FMLA leave?
An employee must provide notice of their need to take FMLA leave and must also provide certification from their healthcare provider stating the expected duration of the leave. Upon returning from FMLA leave, the employee must provide certification from their healthcare provider stating that they are able to resume work. The employee may be required to attend a meeting with their employer to discuss their ability to perform their essential job functions. If the employee is unable to perform their job functions due to a serious health condition, the employer may require the employee to provide additional certification or may offer the employee a reasonable accommodation.
What are the reporting requirements for an employee while on FMLA leave?
An employee is required to provide notice of the need for FMLA leave as soon as practicable and must provide certification from their healthcare provider within 15 calendar days of the request. If the need for leave is foreseeable, the employee must provide at least 30 days' advance notice. If the need for leave is unforeseeable, the employee must provide notice as soon as practicable. The employee is also required to provide notice of any changes in their certification or in their need for leave.
What is the process for requesting an extension of FMLA leave?
An employee may request an extension of FMLA leave by providing additional certification from their healthcare provider. The certification must state the expected duration of the leave and must be provided within 15 calendar days of the request for an extension. The employer may require the employee to provide periodic recertification during the extension period.
What happens if an employee needs more leave than what is available under FMLA?
If an employee needs more leave than what is available under FMLA, they may be able to use other forms of leave, such as vacation, sick leave, or personal days. If the employee does not have any other forms of leave available, they may be able to take an unpaid leave of absence. It is important for the employee to discuss their options with their employer and to provide notice of their need for additional leave as soon as possible.
What is the employer's responsibility to maintain employee records related to FMLA leave?
Employers are required to maintain records related to an employee's FMLA leave for three years. These records include the reason for the leave, the dates of the leave, and any medical certification supporting the leave. Employers must also keep records of any denials of FMLA leave and the reasons for the denials.
What is the impact of FMLA leave on an employee's seniority or other employment rights?
FMLA leave does not affect an employee's seniority status or other employment rights. An employee is entitled to the same seniority status and other employment rights as if they had not taken FMLA leave. However, if an employee's position is eliminated during their FMLA leave due to business reasons unrelated to the leave, the employee may be entitled to certain benefits under the FMLA.
What is the impact of FMLA leave on an employee's retirement benefits?
FMLA leave does not affect an employee's retirement benefits. An employee's use of FMLA leave does not count as service for retirement benefit purposes. However, if an employee's retirement benefits are based on length of employment or hours worked, the employee may want to check with their employer or retirement plan administrator to understand how FMLA leave may affect their retirement benefits.
What is the impact of FMLA leave on an employee's workers' compensation benefits?
FMLA leave and workers' compensation benefits can run concurrently, meaning an employee can take both types of leave at the same time. However, the employee must provide notice of the need for FMLA leave due to a workers' compensation injury or illness to their employer as soon as possible. The employer may require the employee to provide certification from their healthcare provider that the leave is necessary due to the workers' compensation injury or illness.
What is the impact of FMLA leave on an employee's state medical leave law?
FMLA leave runs concurrently with state medical leave laws in some states. This means that an employee can use their FMLA leave and their state medical leave at the same time, up to the maximum amount of leave allowed under both laws. However, if an employee exhausts their FMLA leave before exhausting their state medical leave, they may still be entitled to take unpaid leave under their state medical leave law.
What are the consequences for an employer if they fail to provide FMLA leave or interfere with an employee's FMLA rights?
An employer who violates the Family and Medical Leave Act (FMLA) by failing to provide leave or interfering with an employee's FMLA rights can face serious consequences. The employee may file a complaint with the Wage and Hour Division of the U.S. Department of Labor. If the Department finds that the employer has violated the FMLA, the employer may be required to: 1. Provide the employee with the leave they were denied. 2. Make the employee whole for any wages, salary, employment benefits, or other compensation they lost due to the employer's violation. 3. Pay the employee an additional damages equal to the amount of the employee's lost wages and interest. 4. Pay the employee's reasonable attorney fees and court costs. Additionally, the Department of Labor may impose civil money penalties on the employer, ranging from $2,500 for each violation to $150,000 or more for each violation, depending on the size of the employer and the circumstances of the violation. Employers who willfully or repeatedly violate the FMLA may also be subject to criminal penalties.
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