Form WH-381, Notice of Eligibility Instructions

Check this box when no additional information or documentation is needed from the employee and you should proceed to Section III.

Check this box when the employer requires the employee’s leave to be supported by a certification form (then specify which certification type below).

Check this box when the selected certification form is included/attached with this notice. Fill only if 'Certification requested to support leave' is 'Yes'.

Check this box when the selected certification form is not attached to this notice. Fill only if 'Certification requested to support leave' is 'Yes'.

Enter the deadline date by which the employee must return the requested medical certification to the employer. Fill only if 'Certification requested to support leave' is 'Yes'.

Enter the deadline date by which you must return the requested documentation to establish the family relationship. Fill only if 'Request for documentation of family relationship' is 'Yes'.

Check this box when the employer is asking you to provide reasonable documentation or a statement establishing your relationship to the family member (including in loco parentis) and will require you to return that documentation by the specified due date.

Check this box if you are an airline flight crew employee who, as of the first date of requested leave, has not met the special hours-of-service eligibility requirements (i.e., has not worked or been paid at least 60% of your applicable monthly guarantee and has not worked or been paid at least 504 duty hours).

Check this box if you do not work at and/or report to any site that has 50 or more employees within 75 miles as of the date of your request.

Check this box if you are requesting that the leave be supported by a certification from the employee’s health care provider. Fill only if 'Certification requested to support leave' is 'Yes'.

Check this box if you are requesting that the leave be supported by a certification from the health care provider of the employee’s family member. Fill only if 'Certification requested to support leave' is 'Yes'.

Check this box when the employee meets the Family and Medical Leave Act eligibility requirements and is eligible to take FMLA leave.

Check this box when the employee does not meet FMLA eligibility requirements (and then select the single reason for ineligibility listed below).

Provide the contact information for the person or department responsible for handling employee benefits while you are on FMLA leave.

Specify the location or department where the contact person for employee benefits can be reached.

Enter the name of the employee to whom this notice is addressed.

Enter the full name of the employee to whom this Notice of Eligibility and Rights and Responsibilities is being sent.

Check this box if the employee is considered a key employee as defined under the FMLA.

Check this box if the employee is not considered a key employee as defined under the FMLA.

Check this box if the employee has the required status or condition.

Check this box if the employer has not determined that restoring you to employment at the conclusion of FMLA leave will cause undue hardship.

Enter the full name of the employer representative who can be contacted about this form or the employee's leave.

Provide the employer representative's contact details such as phone number, email address, or office location for follow-up questions.

Check this box when the leave requested is for a qualifying exigency related to a family member's covered active duty or call to covered active duty status (i.e., qualifying exigency FMLA reason). Fill only if 'Certification requested to support leave' is 'Yes'.

Check this box when the leave requested is to care for a covered service member with a serious injury or illness (military caregiver FMLA leave). Fill only if 'Certification requested to support leave' is 'Yes'.

Enter the full name of the employer representative who can be contacted about Section II (e.g., the HR or benefits contact).

Enter the employer representative's contact details such as phone number, email address, and/or mailing address so the employee can reach them with questions about Section II.

Check this box if the family member on covered active duty (or notified of an impending call/order to covered active duty) is your spouse. Fill only if 'Qualifying exigency due to family member's covered active duty' is 'Yes'.

Check this box if the family member on covered active duty (or notified of an impending call/order to covered active duty) is your parent. Fill only if 'Qualifying exigency due to family member's covered active duty' is 'Yes'.

Check this box if the family member on covered active duty (or notified of an impending call/order to covered active duty) is your child of any age. Fill only if 'Qualifying exigency due to family member's covered active duty' is 'Yes'.

Check this box if you are needed to care for your spouse who has a serious health condition. Fill only if 'To care for a family member with a serious health condition' is 'Yes'.

Check this box if you are needed to care for your parent who has a serious health condition. Fill only if 'To care for a family member with a serious health condition' is 'Yes'.

Check this box if you are needed to care for your child under age 18 who has a serious health condition. Fill only if 'To care for a family member with a serious health condition' is 'Yes'.

Check this box if you are needed to care for your child who is 18 or older and is incapable of self-care because of a mental or physical disability and has a serious health condition. Fill only if 'To care for a family member with a serious health condition' is 'Yes'.

Enter the employer's name (and optionally department or contact) who is sending this notice.

Enter the date the notice is completed.

Enter the employee's name.

Enter the full name of the employee who is receiving this notice.

Provide contact information for inquiries about health insurance while on unpaid FMLA leave.

Specify the applicable conditions for the use of paid leave during FMLA leave.

Provide more information about conditions applicable to sick, vacation, or other paid leave usage.

Provide additional information about conditions applicable to sick, vacation, or other paid leave usage.

Specify where the information is available.

Indicate a longer period, if applicable, in which to provide the required information.

Check this box if you have a minimum grace period for providing required information.

Check this box if the minimum grace period is 30 days or another specified period.

Enter the amount of time taken for this reason that will also be designated as FMLA leave and counted against the total FMLA leave entitlement.

Check this box if some or all of your FMLA leave will be unpaid. Any unpaid FMLA leave taken will be designated as FMLA leave.

Check this box if you have requested to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA leave.

Check this box if the employer is requiring you to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA leave.

Check this box if other types of leave (e.g., short- or long-term disability, workers' compensation, state medical leave law) apply.

Check this box if the leave year is based on the calendar year (January 1st - December 31st).

Check this box if the leave year is based on a fixed leave year.

Check this box if the leave year is measured forward from the date of the first FMLA leave usage.

Check this box if the leave year is a rolling 12-month period measured backward from the date of any FMLA leave usage.

Provide details if the leave year is based on a fiscal year (e.g., beginning on July 1 and ending on June 30).

Specify the start date of the single 12-month period for Military Caregiver Leave, if applicable.

Check this box if you will be on leave.

Check this box if you will be available or reachable during your leave.

Provide additional undefined information as required.

Check this box when the employee has not yet worked the required 12 months for FMLA eligibility as of the first date of requested leave (and enter the approximate months worked toward the requirement).

Check this box when the employee has not yet worked the required 1,250 hours for FMLA eligibility as of the first date of requested leave (and enter the approximate hours worked toward the requirement).

Enter the approximate number of months the employee has worked toward the 12‑month employment requirement as of the first date of requested leave. Fill only if 'You have not met the FMLA's 12-month length of service requirement' is 'Yes'.

Enter the approximate number of hours the employee has worked toward the 1,250 hours of service requirement as of the first date of requested leave. Fill only if 'You have not met the FMLA's 1,250 hours of service requirement' is 'Yes'.

Enter the date the employer learned that the employee needs FMLA leave.

Enter the date on which the employee’s FMLA leave is scheduled to begin.

Provide a concise description of the additional information or documentation the employee must submit (for example, details of military family documentation or specific supporting papers). Fill only if 'Other information needed' is 'Yes'.

Enter the date by which the requested information or documentation must be returned to the employer. Fill only if 'Other information needed' is 'Yes'.

Check this box when you require additional documentation or information (for example, documentation for military family leave) beyond the requested medical certification; provide a description of the information requested and the due date in the space provided.

Check this box if you need leave for the birth of a child or the placement of a child with you for adoption or foster care, including time to bond with the newborn or newly-placed child.

Check this box if you need leave because you have a serious health condition that prevents you from performing your job.

Check this box if you need leave to care for a family member who has a serious health condition (then select the family relationship: spouse, parent, child, etc.).

Check this box if you need leave for a qualifying exigency arising because your family member is on covered active duty or has been notified of an impending call or order to covered active duty.

Check this box if you need leave to care for a family member who is a covered servicemember with a serious injury or illness and you are the servicemember's caregiver.

Indicate the interval at which you will provide periodic reports during your FMLA leave, as appropriate for your situation.

Check this box if the covered servicemember you will care for is your spouse. Fill only if 'To care for a covered servicemember with a serious injury or illness (military caregiver leave)' is 'Yes'.

Check this box if the covered servicemember you will care for is your parent. Fill only if 'To care for a covered servicemember with a serious injury or illness (military caregiver leave)' is 'Yes'.

Check this box if the covered servicemember you will care for is your child. Fill only if 'To care for a covered servicemember with a serious injury or illness (military caregiver leave)' is 'Yes'.

Check this box if the covered servicemember you will care for is the servicemember’s next of kin (the person designated as next of kin for FMLA purposes). Fill only if 'To care for a covered servicemember with a serious injury or illness (military caregiver leave)' is 'Yes'.