FMLA Certification of Qualifying Exigency For Military Family Leave

• Legal Form Number: WH-384
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

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.