Form WH-384, Military Family Leave Instructions

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This form contains 68 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Certification
Signature Signature
Provide your signature to certify the information provided.
Date signed Text
Enter the date when the form was signed (mm/dd/yyyy).
Certification Details
List date certification requested Text
Enter the date when the certification was requested.
Return by date Text
Enter the date by which this form must be returned.
Certification Information
II A 4_PREVIOUSLY#20PROVIDED RadioButton
Indicate whether you have previously provided certification for this military family leave.
Childcare Activities Description
Describe childcare activities Text
Provide a description of the childcare activities.
Contact Information
Individual (e.g., name and title) or Entity / Organization Text
Provide the name and title of the individual or the name of the entity/organization.
Address Text
Enter the address of the individual or entity/organization.
undefined Text
Provide additional address details if necessary.
undefined Text
Provide additional address details if necessary.
E-mail Text
Enter the email address of the individual or entity/organization.
Area Code Text
Enter the area code of the primary contact number.
Area Code Text
Enter the area code of the secondary contact number.
Documentation
II A 4_ORDERS RadioButton
Select this option if the documentation provided is military orders.
II A 4_OTHER#20DOC RadioButton
Select this option if the documentation provided is other than military orders.
II 6_ATTACHED RadioButton
Select this option if the required documentation is attached.
II 6_NOT#20ATTACHED RadioButton
Select this option if the required documentation is not attached.
II 6_N#2FA RadioButton
Select this option if the required documentation is not applicable.
Employee Information
First Text
Enter the first name of the employee requesting leave.
Middle Text
Enter the middle name of the employee requesting leave.
Last Text
Enter the last name of the employee requesting leave.
First Text
Enter your first name.
Last Text
Enter the last name of the employee requesting leave.
First Text
Enter the first name of the employee requesting leave.
Last Text
Enter the last name of the employee requesting leave.
Employer Information
Name of Employer Text
Enter the name of the employer to whom this form is being submitted.
Exigency Details
Describe care for military parent Text
Describe the care you will provide for the military parent.
Describe reintigration events Text
Describe the reintegration events you will attend.
Describe purpose of meeting Text
Describe the purpose of the meeting.
Exigency Timing
List the approximate date exigency started or will start Text
List the approximate date when the exigency started or will start.
Leave Details
Over the next 6 months, absences on an intermittent basis are estimated to occur Text
Estimate the number of absences on an intermittent basis over the next 6 months.
month) and are likely to last approximately Text
Estimate the duration of each absence.
From Text
Enter the start date of the leave period (mm/dd/yyyy).
mm/dd/yyyy) to Text
Enter the end date of the leave period (mm/dd/yyyy).
II 11_DAY RadioButton
Select this option if the leave is for a single day.
Leave Duration
II 11_WEEK RadioButton
Select this option if the leave needed is measured in weeks.
II 11_MONTH RadioButton
Select this option if the leave needed is measured in months.
II 11 2_HOURS RadioButton
Select this option if the leave needed is measured in hours.
II 11 2_DAYS RadioButton
Select this option if the leave needed is measured in days.
Leave Period
From Text
Enter the start date of the leave period in mm/dd/yyyy format.
mm/dd/yyyy) to Text
Enter the end date of the leave period in mm/dd/yyyy format.
From Text
Enter the start date of the leave period in mm/dd/yyyy format.
mm/dd/yyyy) to Text
Enter the end date of the leave period in mm/dd/yyyy format.
From Text
Enter the start date of the leave period in mm/dd/yyyy format.
mm/dd/yyyy) to Text
Enter the end date of the leave period in mm/dd/yyyy format.
Military Events Description
First Text
Enter the first name of the person describing the military events.
Last Text
Enter the last name of the person describing the military events.
Describe military events Text
Provide a description of the military events.
Military Family Member Information
First Text
Enter the first name of the military family member.
Middle Text
Enter the middle name of the military family member.
Last Text
Enter the last name of the military family member.
Military Family Member Relationship
II 2_SPOUSE RadioButton
Select this option if the military family member is the employee's spouse.
II 2_PARENT RadioButton
Select this option if the military family member is the employee's parent.
II 2_CHILD RadioButton
Select this option if the military family member is the employee's child.
Military Service Details
Dates of military service Text
Enter the dates of the military service for the family member.
Nature of Exigency
Care for the military member’s parent (e.g., admitting or transferring the parent to a new care facility CheckBox
Check this box if the leave is to care for the military member’s parent, such as admitting or transferring the parent to a new care facility.
Financial and legal arrangements related to the deployment (e.g., obtaining military identification cards CheckBox
Check this box if the leave is for making financial and legal arrangements related to the deployment, such as obtaining military identification cards.
Counseling related to the deployment (i.e., counseling provided by someone other than a health care provider CheckBox
Check this box if the leave is for counseling related to the deployment, provided by someone other than a health care provider.
Military member’s short-term, temporary Rest and Recuperation leave (R&R) (leave for this reason is limited CheckBox
Check this box if the leave is for the military member’s short-term, temporary Rest and Recuperation leave (R&R).
Post deployment activities (e.g., arrival ceremonies, or reintegration briefings and events CheckBox
Check this box if the leave is for post-deployment activities, such as arrival ceremonies or reintegration briefings and events.
Any other event that the employee and employer agree is a qualifying exigency CheckBox
Check this box if the leave is for any other event that you and your employer agree is a qualifying exigency.
Reintigration events continued Text
Provide additional details about reintegration events if needed.
Describe exigency event Text
Describe the exigency event for which you are requesting leave.
Exigency events continued Text
Provide additional details about the exigency events if needed.
Qualifying Exigency
Short notice deployment (i.e., deployment within seven or fewer days of notice CheckBox
Check this box if the leave is due to a short notice deployment (i.e., deployment within seven or fewer days of notice).
Military events and related activities (e.g., official ceremonies or events, or family support and assistance programs CheckBox
Check this box if the leave is for military events and related activities (e.g., official ceremonies or events, or family support and assistance programs).
Childcare related activities for the child of the military member (e.g., arranging for alternative childcare CheckBox
Check this box if the leave is for childcare related activities for the child of the military member (e.g., arranging for alternative childcare).
Work Ability
I am able to work Text
Indicate whether you are able to work during the leave period.