This form contains 79 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Information
No additional info	CheckBox	Check this box if no additional information is required from the employee.
Other information needed (e.g. documentation for military family leave)	Text	Provide any other necessary information, such as documentation for military family leave.
Other information needed (e.g. documentation for military family leave	CheckBox	Check this box if other information, such as documentation for military family leave, is needed.
Certification
Certification requested	CheckBox	Check this box if a certification is requested from the employee.
Certification requested_HCP	RadioButton	Select this radio button if a certification is requested from the Health Care Provider for the employee.
Health Care Provider for the Employee’s Family Member	RadioButton	Select this radio button if a certification is requested from the Health Care Provider for the employee’s family member.
Certification requested_Exigency	RadioButton	Select this radio button if a certification is requested for a qualifying exigency.
Serious Illness or Injury (Military Caregiver Leave	RadioButton	Select this radio button if a certification is requested for a serious illness or injury (Military Caregiver Leave).
Certification attached_YES	RadioButton	Select this radio button if the certification is attached.
Certification attached_NO	RadioButton	Indicate whether the certification is attached by selecting 'No'.
If requested, medical certification must be returned by	Text	Specify the deadline by which the medical certification must be returned if requested.
must be returned to us by	Text	Specify the deadline by which the requested information must be returned.
The information requested must be returned to us by	Text	Specify the deadline by which the requested information must be returned.
Certification of family relationship requested	CheckBox	Check this box if certification of family relationship is requested.
Contact Information
If you have any questions, please contact	Text	Enter the contact person for any questions regarding this notice.
Contact info	Text	Enter the contact information (phone number, email, etc.) for the person to contact with questions.
(Name	Text	Provide the name of the contact person if there are any questions.
at	Text	Provide the contact details (e.g., phone number or email) for the person to contact if there are any questions.
Eligibility Status
Eligible for FMLA leave. (See Section II for any Additional Information Needed and Section III for information on your Rights	CheckBox	Check this box if the employee is eligible for FMLA leave. Refer to Section II for any additional information needed and Section III for information on rights.
Not eligible for FMLA leave because: (Only one reason need be checked	CheckBox	Check this box if the employee is not eligible for FMLA leave. Only one reason needs to be checked.
You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave	CheckBox	Check this box if the employee has not met the FMLA’s 12-month length of service requirement as of the first date of requested leave.
You have not met the FMLA’s 1,250 hours of service requirement. As of the first date of requested leave, you	CheckBox	Check this box if the employee has not met the FMLA’s 1,250 hours of service requirement as of the first date of requested leave.
(months)	Text	Enter the number of months towards meeting the FMLA’s length of service requirement.
towards this requirement	Text	Enter the number of hours towards meeting the FMLA’s hours of service requirement.
Employee Benefits
your employee benefits while you are on FMLA leave, contact	Text	Provide the contact information for the person or department responsible for handling employee benefits while you are on FMLA leave.
at	Text	Specify the location or department where the contact person for employee benefits can be reached.
Employee Information
(Employer) To	Text	Enter the name of the employee to whom this notice is addressed.
Airline employee	CheckBox	Check this box if the employee is an airline flight crew member.
Employee	Text	Enter the name of the employee.
Employee	Text	Enter the employee's name.
Employee	Text	Enter the name of the employee requesting FMLA leave.
Employee Status
are	CheckBox	Check this box if the employee is considered a key employee as defined under the FMLA.
are not) considered a key employee as defined under the FMLA. Your FMLA leave cannot be denied for	CheckBox	Check this box if the employee is not considered a key employee as defined under the FMLA.
have	CheckBox	Check this box if the employee has the required status or condition.
Employer Determination
have not) determined that restoring you to employment at the conclusion of FMLA leave will cause	CheckBox	Check this box if the employer has not determined that restoring you to employment at the conclusion of FMLA leave will cause undue hardship.
Employer Information
From	Text	Enter the name of the employer or the entity providing this notice.
Date	Text	Enter the date when this notice is being issued.
50 employees	CheckBox	Check this box if the employer has 50 or more employees.
Family Member Information
Spouse	CheckBox	Check this box if the family member you are caring for is your spouse.
Parent	CheckBox	Check this box if the family member you are caring for is your parent.
Child under age 18	CheckBox	Check this box if the family member you are caring for is your child under age 18.
Child 18 years or older and incapable of self	CheckBox	Check this box if the family member you are caring for is your child 18 years or older and incapable of self-care.
Spouse	CheckBox	Check this box if the family member you are caring for is your spouse.
Parent	CheckBox	Check this box if the family member you are caring for is your parent.
Child of any age	CheckBox	Check this box if the family member you are caring for is your child of any age.
Spouse	CheckBox	Check this box if the family member you are caring for is your spouse.
Parent	CheckBox	Check this box if the family member you are caring for is your parent.
Child	CheckBox	Check this box if the family member you are caring for is your child.
Next of kin	CheckBox	Check this box if the family member you are caring for is your next of kin.
Health Insurance
on your health insurance while you are on any unpaid FMLA leave, contact	Text	Provide contact information for inquiries about health insurance while on unpaid FMLA leave.
Leave Conditions
The applicable conditions for use of paid leave include	Text	Specify the applicable conditions for the use of paid leave during FMLA leave.
For more information about conditions applicable to sick/vacation/other paid leave usage please refer to	Text	Provide more information about conditions applicable to sick, vacation, or other paid leave usage.
For more information about conditions applicable to sick/vacation/other paid leave usage please refer to [2	Text	Provide additional information about conditions applicable to sick, vacation, or other paid leave usage.
available at	Text	Specify where the information is available.
indicate longer period, if applicable) in which to	Text	Indicate a longer period, if applicable, in which to provide the required information.
You have a minimum grace period of	CheckBox	Check this box if you have a minimum grace period for providing required information.
30-days or	CheckBox	Check this box if the minimum grace period is 30 days or another specified period.
Leave Details
Any time taken for this reason will also be designated as FMLA leave and counted against the amount of	Text	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.
Leave Information
mm/dd/yyyy), we learned that you need leave (beginning on	Text	Enter the date (mm/dd/yyyy) when the need for leave was identified.
(mm/dd/yyyy9c7e	Text	Enter the date (mm/dd/yyyy) when the leave is expected to begin.
Leave Payment
Some or all of your FMLA leave will not be paid. Any unpaid FMLA leave taken will be designated as FMLA	CheckBox	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.
You have requested to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA	CheckBox	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.
We are requiring you to use some or all of your available paid leave (e.g., sick, vacation, PTO) during your FMLA	CheckBox	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.
Other: (e.g., short-or long-term disability, workers’ compensation, state medical leave law, etc	CheckBox	Check this box if other types of leave (e.g., short- or long-term disability, workers' compensation, state medical leave law) apply.
Leave Period
The calendar year (January 1st -December 31st	CheckBox	Check this box if the leave year is based on the calendar year (January 1st - December 31st).
A fixed leave year based on	CheckBox	Check this box if the leave year is based on a fixed leave year.
The 12-month period measured forward from the date of your first FMLA leave usage	CheckBox	Check this box if the leave year is measured forward from the date of the first FMLA leave usage.
A “rolling” 12-month period measured backward from the date of any FMLA leave usage. (Each time an employee	CheckBox	Check this box if the leave year is a rolling 12-month period measured backward from the date of any FMLA leave usage.
e.g., a fiscal year beginning on July 1 and ending on June 30	Text	Provide details if the leave year is based on a fiscal year (e.g., beginning on July 1 and ending on June 30).
If applicable, the single 12-month period for Military Caregiver Leave started on	Text	Specify the start date of the single 12-month period for Military Caregiver Leave, if applicable.
Leave Status
While on leave you	CheckBox	Check this box if you will be on leave.
will be	CheckBox	Check this box if you will be available or reachable during your leave.
Miscellaneous
undefined	Text	Provide additional undefined information as required.
Reason for Leave
The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or	CheckBox	Check this box if the leave is requested for the birth of a child, or placement of a child for adoption or foster care, and to bond with the newborn or newly placed child.
Your own serious health condition	CheckBox	Check this box if the leave is requested due to 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	CheckBox	Check this box if the leave is requested to care for a family member with a serious health condition. Specify the family member's relationship to you.
A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of	CheckBox	Check this box if the leave is requested due to a qualifying exigency arising from a family member's covered active duty or notification of an impending call to active duty.
You are needed to care for your family member who is a covered servicemember with a serious injury or illness. You	CheckBox	Check this box if the leave is requested to care for a family member who is a covered servicemember with a serious injury or illness.
Reporting Requirements
(Indicate interval of periodic reports, as appropriate for the FMLA leave situation)	Text	Indicate the interval at which you will provide periodic reports during your FMLA leave, as appropriate for your situation.

Form WH-381, Notice of Eligibility Instructions