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.
Form WH-381, Notice of Eligibility has a moderate Form Complexity Index of 56/100 — Instafill’s AI completes it in under a minute.
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Completed WH-381 Form for an employee's medical leave

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
Completed WH-381 Form for an employee's medical leave