Certification for Military Family Leave for U.S. Department of Labor
Qualifying Exigency Wage and Hour Division
under the Family and Medical Leave Act
Page 1 of 4 Form WH-384, Revised June 2020
DO NOT SEND FORM TO THE DEPARTMENT OF LABOR.
RETURN THE COMPLETED FORM TO THE EMPLOYER.
OMB Control Number:
1235-0003 Expires: 6/30/2026
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave for a qualifying
exigency while the employee's spouse, child, or parent (the military member) is on covered active duty or has been notified
of an impending call or order to covered active duty. The FMLA allows an employer to require an employee seeking FMLA
leave due to a qualifying exigency to submit a certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the
employee at least 15 calendar days to provide the certification. 29 C.F.R. § 825.305(b). If the employee fails to provi de
complete and sufficient certification, the employee’s FMLA leave request may be denied. 29 C.F.R. § 825.313. Information
about the FMLA may be found on the WHD website at http://www.dol.gov/agencies/whd/fmla.
SECTION I - EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, it asks the employee for
the information necessary for a complete and sufficient qualifying exigency certification, which is set out at 29 C.F.R. §
825.309. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29
C.F.R. § 825.309.
(1) Employee name: ________________________________________________________________________
First Middle Last
(2) Employer name: __________________________________________ Date: _____________________ (mm/dd/yyyy)
(List date certification requested)
(3) This certification must be returned by_____________________________________________________________ (mm/dd/yyyy).
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s diligent, good faith efforts.)
SECTION II - EMPLOYEE
Please complete all Parts of Section II and sign the form before returning it to your employer. The FMLA allows an employer
to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a
qualifying exi gency. If requested by your employer, your response is required to obtain the benefits and protections of the
FMLA. 29 C.F.R. § 825.309. Failure to provide a complete and sufficient certification may result in a denial of your FMLA
leave request. A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency
includes written documentation confirming a military member’s covered active duty or call to covered active duty status.
You are responsible for making sure the certification is provided to your employer within the time frame requested,
which must be at least 15 calendar days. 29 C.F.R. § 825.313.
(1) Provide the name of the military member on covered active duty or call to covered active duty status:
First Middle Last
(2) Select your relationship of the military member . The military member is your:
Spouse Parent Child, of any age
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common
law marriage or same-sex ma rriage. 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 for a qualifying exigency related a military
member who assumed the obligations of a parent to the employee when the employee was a child. An employee may al so take
FMLA leave for a qualifying exigency related a military member for whom the employee has assumed the obligations of a
parent. No legal or biological relationship is necessary.