____ _ ___
____ _ ___ _
____________________________________________________________________________ ____________________________________________ __________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________
____________________________________________________________________________ ____________________________________________ __________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ _____________ ____________ __________ __________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Notice of Eligibility and Rights & U.S. Department of Labor
Responsibilities
Wage and Hour Division
(Family and Medical Leave Act)
_
OMB Control Number: 1235-0003
Expires: 5/31/2018
In general, to be eligible 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 by employers is optional, a
fully completed Form WH-381 provides employees with the information required by 29 C.F.R. § 825.300(b), which must be provided within
five business days of the employee notifying the employer of the need for FMLA leave. Part B provides employees with information
regarding their rights and responsibilities for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).
[Part A – NOTICE OF ELIGIBILITY]
TO: _________
____________
___________________
Employee
FROM: _________ _______________________________
Employer Representative
DATE: _________ _______________________________
On _____________________, y
ou informed us
that you needed leave beginning on _______________________ for:
_____ The birth of a child, or placement of a child with you for adoption or foster care;
_____ Your own serious health condition;
_____ Because you are needed to care for your ____ spouse; _____child; ______ parent due to his/her serious health condition.
_____
Because of a qualifying exigency arising out of the fact that your ____ spouse; _____son or daughter; ______ parent is on covered
active duty or call to covered
active duty status with the Armed Forces.
_____ Because you are the ____ spouse; _____son or daughter; ______ parent; _______ next of kin of a covered service
member with a
seriou
s injury or illness.
This Notice is to inform you that you:
_____
Are eligible for FMLA leave (S
ee Part B below for Rights and Responsibilities)
_____ Are not eligible for FMLA leave, because (only
one reason need be checked, although you m
ay not be eligible for other reasons):
_____ You have not
met the FMLA’s
12-
m
o
nth lengt
h of service require
m
ent. As of the first date o
f requested leave, you will
have worked approximately ___ months towards this requirement.
_____ You have not
met the FMLA’s hours of service require
ment.
_____ You do not work and/or report to a site with 50 or more emplo
yees within 75-miles.
If you have any questions, contact ___________________________________________________ or view the
FMLA poster located in
_________________________________________________________________________.
[PART B-RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE]
As explained in Part A, you meet the eligibilit y requirements for taking F MLA leave and still have FMLA leave available in the applicable
12-month period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must return the
following information to us b
y ___________________________________. (If a certification is requested, employers must allow at least
15
calendar days from receipt
of this notice; additional time may be required in some circum
stances.) If sufficient information is not
provided in
a timely manner, your leave may be denied.
____ Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to support your
request ____is/____ is not enclosed.
____ Sufficient documentation to establish the required relationship between you and your family member.
____ Other information needed (such as documentation for military family leave): ________________________________________________________
____ No additional information requested
Page 1 CONTINUED ON NEXT PAGE Form WH-381 Revised February 2013
____ _ ___ _
_
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
____________________________________________________________________________ ____________________________________________ __________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________
____________________________________________________________________________________________________________________________________________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ _________
If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave (only checked blanks apply):
____ Contact _____________________________________ at ___________________________ to make arrangements to continue to make your share
of the premium payments on your health insurance t o maintain health benefits while you are on leave. You have a minimum 30-day (or, indicate
longer period, if applicable) grace period in which to
make premium payments. If payment is
not made timely, your group health insurance may be
cancelled, provide
d we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your
share of the premiums during FMLA leave, and recover these payments from you upon your return to work.
____ You will be required to use your available paid ______ sick, _______ vacation, and/or ________other leave during y
our FMLA absence. This
means that you will receive your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave
entitlement.
____ Due to your status within the company, you are considered a “key
employee” as define
d in the FMLA. As a “key employee,” restoration to
employment may
be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us.
We ___have/____ have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous
economic harm to us.
____ While on leav
e you will be required to furnish us with periodic reports of your status and intent to return to work every __________
____________.
(Indicate interval of periodic reports, as appropriate for the particular leave situation).
If the circumstances of your leave change, and you are able to return to wo
rk earlier than the date indicated on the this form, you will be required
to notify us
at least two workdays prior to the date you intend to report for work.
If your leave does qualify as
FMLA leave you will have the following rights while on FMLA leave:
You have a right under the FMLA for up to 12 week
s of unpaid leave in a 12-month period calculated as:
_____ the calendar year (January – December).
_____ a fixed leave year based on _______________________________________________________________________________________.
_____ the 12-month period measured forward from the date
of your first FMLA leave usage.
_____ a “rolling” 12-month period measured backward from the date of any FMLA leave usage.
You have a right
under the FMLA for up to 26 weeks of unpaid leave in a single 1
2-month period to care for a covered servicemember with a serious
injury or illness. This single 12-month period commenced on ________________________________________________________________________.
Your health benef
its must be maintained during any period of unpaid leave under the same conditions as if you continued to work.
You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from
FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not
have return rights under FMLA.)
If you do not return to work following FMLA leave for a reason other than: 1) the continuation, recurrence, or onset of a serious health condition which
would entitle you to FMLA leave; 2) the continuation, recurrence, or onset of a covered servicemember’s serious injury or illness which wo
uld entitle
you to FMLA leave; or 3) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums
paid on your behalf during your FMLA leave.
If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA leave entitlement, you have the right to have
____ sick, ____vacation, and/or ___ other leave run concurrently with your unpaid le
ave entitlement, provided you meet any applicable requirements
of the leave policy. Applicable conditions related to the substitution of paid leave are referenced or set forth below. If you do not meet the requirements
for taking paid leave, you remain entitled to take unpaid FMLA leave.
____For
a copy of conditions applicable to sick/vacation/other leave usage please refer to ____________ available at: ___________________________.
____Applicable conditions for use of paid leave:_____________________________________________
______________________________________
Once we obtain th
e information from you as specified above, we will inform you, within 5 business days, whether your leave will be designated as
FMLA leave and count towards your FMLA leave entitlement. If you have any questions, please do not hesitate to
contact:
_______________________________________________at ______________________________________.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
It is mandatory for employers to provide employees with notice of their eligibility for FMLA protection and their rights and responsibilities. 29 U.S.C. § 2617; 29
C.F.R. § 825.300(b), (c). It is mandatory for em
ployers to retain a copy of this disclosure in their recor
ds for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it
will take an average of 10 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden
estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division,
U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WA
GE
AND HOUR DIVISION.
Page 2 Form WH-381 Revised February 2013
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