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Notice of Eligibility & Rights and Responsibilities 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: 6/30/2023
In general, to be eligible to take leave under the Family and Medical Leave Act (FMLA), an employee must have worked
for an employer for at least 12 months, meet the hours of service requirement in the 12 months preceding the leave, and
work at a site with at least 50 employees within 75 miles. While use of this form is optional, a fully completed Form WH-
381 provides employees with the information required by 29 C.F.R. §§ 825.300(b), (c) which must be provided within five
business days of the employee notifying the employer of the need for FMLA leave. Information about the FMLA may be
found on the WHD website at www.dol.gov/agencies/whd/fmla .
Date: ___________________________ (mm/dd/yyyy)
From: ___________________________________ (Employer) To: ______________________________________ (Employee)
On __________________(mm/dd/yyyy), we learned that you need leave(beginning on) _____________________(mm/dd/yyyy)
for one of the following reasons: (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
You are needed to care for your family member due to a serious health condition. Your family member is your:
Spouse Parent Child under age 18 Child 18 years or older and incapable of self-
care because of a mental or physical disability
A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of
an impending call or order to covered active duty status. Your family member on covered active duty is your:
Spouse Parent Child of any age
You are needed to care for your family member who is a covered servicemember with a serious injury or illness. You
are the servicemember’s:
Spouse Parent Child Next of kin
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in a common law
marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which a person assumes the
obligations of a parent to a child. An employee may take FMLA leave to care for an individual who assumed the obligations of a parent
to the employee when the employee was a child. An employee may also take FMLA leave to care for a child for whom the employee
has assumed the obligations of a parent. No legal or biological relationship is necessary.
SECTION I – NOTICE OF ELIGIBILITY
This Notice is to inform you that you are:
Eligible for FMLA leave.(See Section II for any Additional Information Needed and Section III for information on your Rights
and Responsibilities.)
Not eligible for FMLA leave because: (Only one reason need be checked)
You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave,
you will have worked approximately: __________ towards this requirement.
(months)
You have not met the FMLA’s 1,250 hours of service requirement. As of the first date of requested leave, you
will have worked approximately: _______________towards this requirement.
(hours of service)
Page 1 of 4 Form WH-381, Revised June 2020
