Form WH-381, Notice of Eligibility Completed Form Examples and Samples
Explore a complete example of Form WH-381, filled to demonstrate how to request an employee medical leave under the Family and Medical Leave Act. Perfect for HR professionals and employees seeking guidance on accurate completion.
WH-381 Example – Employee Request for Leave
How this form was filled:
This example illustrates how to fill out Form WH-381 for an employee's medical leave request due to a serious health condition. It includes essential details such as the employee's name, employer's information, leave request dates, and relevant medical condition description.
Information used to fill out the document:
- Employer Name: Greenfield Industries
- Employer Address: 456 Corporate Blvd, Metropolis, USA
- Employee Name: Alice Johnson
- Employee ID: EMP12345
- Type of Leave: Medical Leave
- Leave Start Date: 03/01/2025
- Leave End Date: 05/01/2025
- Medical Condition: Serious health condition requiring surgery
- Supervisor's Name: Robert Green
- Contact Information: [email protected]
What this filled form sample shows:
- Comprehensive employer and employee information for accurate processing
- Specific leave dates and type of leave to avoid miscommunication
- Detailed medical condition description justifying the leave request
- Proper supervisor approval with contact information for follow-up
Form specifications and details:
| Use Case: | Employee requesting medical leave due to a serious health condition |
