Employee Name: ___________________________________________________________________________________________
Page 2 of 4 For
m WH-384, Revised June 2020
PART A: COVERED ACTIVE DUTY STATUS
Covered active duty or call to covered active duty in the case of a member of the Regular Armed Forces means duty during
the deployment of the member with the Armed Forces to a foreign country. Covered active duty or call to covered active
duty in the case of a member of the Reserve components means duty during the deployment of the member with the Armed
Forces to a foreign country under a Federal call or order to active duty in support of a contingency operation pursuant to:
Section 688 of Title 10 of the United States Code; Section 12301(a) of Title 10 of the United States Code; Section 12302
of Title 10 of the United States Code; Section 12304 of Title 10 of the United States Code; Section 12305 of Title 10 of
the United States Code; Section 12406 of Title 10 of the United States Code; chapter 15 of Title 10 of the United States
Code; or, any other provision of law during a war or during a national emergency declared by the President or Congress
so long as it is in support of a contingency operation. 10 U.S.C. § 101(a)(13)(B).
An empl
oyer may require the employee to provide a copy of the military member's active duty orders or other
documentation issued by the military which indicates that the military member is on covered active duty or call to covered
active duty status, and the dates of the military member's covered active duty service. This information need only be
provided to the employer once, unless additional leave is needed for a different military member or different
deployment.
(3) Prov
ide the dates of the military member’s covered active duty service: __________________________________
(4) Please ch
eck one of the following and attach the indicated written document to support that the military member
is on covered active duty or call to covered active duty status:
A copy of
the military member’s covered active duty orders
Other
documentation from the military indicating that the military member is on covered active duty or has
been notified of an impending call to covered active duty, such as official military correspondence from the
military member’s chain of command
I have
previously provided my employer with sufficient written documentation confirming the military
member’s covered active duty or call to covered active duty status
PART B: APPROPRIATE FACTS
Under the FMLA, leave can be taken for a number of qualifying exigencies. 29 C.F.R. § 825.126(b). Complete and
sufficient certification to support a request for FMLA leave due to a qualifying exigency includes available written
documentation which supports the need for leave such as a copy of a meeting announcement for informational briefings
sponsored by the military, a document confirming the military member’s Rest and Recuperation leave, or other
documentation issued by the military which indicates that the military member has been granted Rest and Recuperation
leave, or a document confirming an appointment with a third party (e.g., a counselor or school official, or staff at a care
facility, a copy of a bill for services for the handling of legal or financial affairs). Please provide appropriate facts related
to the particular qualifying exigency to support the FMLA leave request, including information on the type of qualifying
exigency and any available written documentation of the exigency event.
(5) Select the appropriate Qualifying Exigency Category and, if needed, provide additional information related to
the event:
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):
_________________________________________________________________________________________________
Childc
are related activities for the child of the military member
(e.g., arranging for alternative childcare):
____________________________________________________________________________________________________________
