FMLA Designation Notice

• Legal Form Number: WH-382
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

Designation Notice U.S. Department of Labor

under the Family and Medical Leave Act Wage and Hour Division

Page 1 of 2 Form WH-382, Revi sed June 2020

DO NOT SEND TO THE DEPARTM ENT OF LABOR.

PROVIDE TO EMPLOYEE.

OMB Control Number: 1235-0003

Expires: 6/30/2026

Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform

the employee of the amount of leave that will be counted against the e mployee’s FMLA leave entitlement. In order to determine whether

leave is covered under the FMLA, the employer may request that the leave be supported by a certification. If the certification is

incomplete or insufficient, the employer must state in writing what additio nal information is necessary to make the certification complete

and sufficient. While use of this form is optional, a fully completed Form WH-382 provides employees with the information required

by 29 C.F.R. §§ 825.300(d), 825.301, and 825.305(c), which must be provided within five busine ss days of the employer having enough

information to determine whether the leave is for an FMLA-qualifying reason. Information about the FMLA may be found on the WHD

website at www.dol.gov/agencies/whd/ fmla.

SECTION I - EMPLOYER

The employer is responsible in all circumstances for designating leave as FMLA-qualifying and givi ng notice to the employee. Once an

eligible employee communicates a need to take leave for an FMLA-qualifying reason, an employer ma y not delay designatin g such

leave as FMLA leave, and neither the employee nor the employer may decline FMLA protection for that leave.

Date: ____________________________ (mm/dd/yyyy)

From: _______________________________________ (Employer) To: _____________________________________ (Employee)

On _____________________ (mm/dd/yyyy) we received your most recent information to support your need for leave due to:

(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 ne wly-

placed child

Your own serious healt h condition

The serious health co ndition of your spouse, child, or parent

A qualifying exigenc y arising out of the fact that your spouse, child, or parent is o n covered active duty or has been notified

of an impending call or order to covered active duty with the Armed Forces

A serious injury or illness of a covered serviceme mber where you are the servicemember’s spouse, child, parent, or next of

kin (Military Caregiver Leave)

We have reviewed information related to your need for leave under the FMLA along with any supporting documentation

provided and decided that your FMLA leave request is: (Select as appropriate)

Approved. All leave taken for this reason will be designated as FMLA leave. Go to Section III for more i nformation.

Not Approved: (Select as appropriate)

The FMLA does not apply to your leave request.

As of the date the leave is to start, you do not have any FMLA leave available to use.

Other _______________________________________________________________________

Additional information is needed to determine if your leave request qualifies as FMLA leave. (Go to Section II for the specific

information needed. If your FMLA leave request is approved and no additional information is needed, go to Section III.)

SECTION II – ADDITIONAL INFORMATION NEEDED

We need additional information to determine whether your leave request qualifies under the FMLA. Once we obtain the additional

information requested, we will inform you within 5 business days if your leave will or will not be designated as FMLA leave and count

towards the amount of FMLA leave you have available. Failure to provide the additional information as requested may result in a

denial of your FMLA leave request.

If you have any questio ns, please contact: _____________________________________at___________________________________

(Name of employer FMLA representative) (Contact information)

Incomplete or Insufficient Certification

The certification you have provided is incomplete and/or ins ufficient to determine whether the FMLA applies to your leave request.

(Select as applicable)

The certification provided is incomplete and we are unable to determine whether the FMLA applies to your leave

request. “Incomplete” means one or more of the applicable entries on the certification have not been completed.