Form WH-382, Designation Notice Instructions

Check this box if the certification provided is insufficient to determine whether the FMLA applies to the leave request.

Specify the information needed to make the certification complete and/or sufficient. Provide detailed information.

Specify additional information needed to make the certification complete and/or sufficient. Provide detailed information.

Enter the deadline by which the requested information must be provided. Ensure it is at least 7 calendar days from the current date.

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

Enter the recipient's name or the entity to whom the notice is addressed.

Enter the name of the employer's FMLA representative.

Enter the contact information for the employer's FMLA representative.

Select this option if the leave WILL BE designated as FMLA-protected.

Select this option if the leave WILL NOT BE designated as FMLA-protected.

Select this option if the leave IS FMLA-eligible.

Select this option if the leave IS NOT FMLA-eligible.

Enter the date when the form is being filled out.

Select the appropriate option that applies to the leave request.

Check this box if the leave is approved and will be designated as FMLA leave. Refer to Section III for more information.

Check this box if the leave is not approved. Select the appropriate reason for denial.

Check this box if additional information is needed to determine if the leave request qualifies as FMLA leave. Refer to Section II for specifics.

Check this box if the FMLA does not apply to the leave request.

Check this box if the employee does not have any FMLA leave available as of the start date of the leave.

Check this box for other reasons not listed for the leave decision.

Check this box if the certification provided is incomplete and it is not possible to determine whether the FMLA applies to the leave.

Specify the amount of leave that will be counted against the employee's leave entitlement.

Enter the date (mm/dd/yyyy) when the most recent information supporting the need for leave was received.

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

Check this box if some or all of the employee's available paid leave (e.g., sick, vacation, PTO) will be used during the FMLA leave based on the employee's request.

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

Check this box if there is no change from the anticipated FMLA leave schedule and specify the number of hours, days, or weeks.

Check this box if the leave will be unscheduled and it is not possible to provide the exact hours, days, or weeks.

Check this box if you are requesting the employee to obtain a medical certification.

Check this box if you are requesting a second medical opinion.

Check this box if you are requesting a third medical opinion at the employer's expense.

This field is undefined and may not be necessary to fill out.

Check this box if there are other conditions or requirements not specified in the form.

Check this box if the leave is due to the birth of a child.

Check this box if the leave is due to a serious health condition of the employee.

Check this box if the leave is due to a serious health condition of a dependent.

Check this box if the leave is due to a qualifying exigency arising out of the fact that the employee's spouse, son, daughter, or parent is on covered active duty or has been notified of an impending call or order to covered active duty in the Armed Forces.

Check this box if the leave is for military caregiver leave.

Specify if the leave is related to short-term or long-term disability, workers' compensation, state medical leave law, etc. Provide details about any time taken for this reason.