Enlarge image
Designation Notice U.S. Department of Labor under the Family and Medical Leave Act Wage and Hour Division DO NOT SEND TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003 PROVIDE TO EMPLOYEE. Expires: 6/30/2026 Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform the employee of the amount of leave that will be counted against the employee’s FMLA leave entitlement. In order to determine whether leave is covered under the FMLA, the employer may request that the leave be supported by a certification. If the certification is incomplete or insufficient, the employer must state in writing what additional information is necessary to make the certification complete and sufficient. While use of this form is optional, a fully completed Form WH-382 provides employees with the information required by 29 C.F.R. §§ 825.300(d), 825.301, and 825.305(c), which must be provided within five business days of the employer having enough information to determine whether the leave is for an FMLA-qualifying reason. Information about the FMLA may be found on the WHD website at www.dol.gov/agencies/whd/fmla. SECTION I - EMPLOYER The employer is responsible in all circumstances for designating leave as FMLA-qualifying and giving notice to the employee. Once an eligible employee communicates a need to take leave for an FMLA-qualifying reason, an employer may not delay designating such leave as FMLA leave, and neither the employee nor the employer may decline FMLA protection for that leave. Date: ____________________________ (mm/dd/yyyy) From: _______________________________________ (Employer) To: _____________________________________ (Employee) On _____________________ (mm/dd/yyyy) we received your most recent information to support your need for leave due to: (Select as appropriate) The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or newly- placed child Your own serious health condition The serious health condition of your spouse, child, or parent A qualifying exigency arising out of the fact that your spouse, child, or parent is on covered active duty or has been notified of an impending call or order to covered active duty with the Armed Forces A serious injury or illness of a covered servicemember where you are the servicemember’s spouse, child, parent, or next of kin (Military Caregiver Leave) We have reviewed information related to your need for leave under the FMLA along with any supporting documentation provided and decided that your FMLA leave request is: (Select as appropriate) Approved. All leave taken for this reason will be designated as FMLA leave. Go to Section III for more information. Not Approved: (Select as appropriate) The FMLA does not apply to your leave request. As of the date the leave is to start, you do not have any FMLA leave available to use. Other _______________________________________________________________________ Additional information is needed to determine if your leave request qualifies as FMLA leave. (Go to Section II for the specific information needed. If your FMLA leave request is approved and no additional information is needed, go to Section III.) SECTION II – ADDITIONAL INFORMATION NEEDED We need additional information to determine whether your leave request qualifies under the FMLA. Once we obtain the additional information requested, we will inform you within 5 business days if your leave will or will not be designated as FMLA leave and count towards the amount of FMLA leave you have available. Failure to provide the additional information as requested may result in a denial of your FMLA leave request. If you have any questions, please contact: _____________________________________at___________________________________ (Name of employer FMLA representative) (Contact information) Incomplete or Insufficient Certification The certification you have provided is incomplete and/or insufficient to determine whether the FMLA applies to your leave request. (Select as applicable) The certification provided is incomplete and we are unable to determine whether the FMLA applies to your leave request. “Incomplete” means one or more of the applicable entries on the certification have not been completed. Page 1 of 2 Form WH-382, Revised June 2020
