FMLA Notice of Eligibility and Rights & Responsibilities

• Legal Form Number: WH-381
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

Notice of Eligibility & Rights and Responsibilities U.S. Department of Labor

under the Family and Medical Leave Act Wage and Hour Division

DO NOT SEND TO THE DEPARTMENT OF LABOR.

PROVIDE TO EMPLOYEE.

OMB Control Number: 1235-0003

Expires: 6/30/2026

In general, to be eligible to take leave under the Family and Medical Leave Act (FMLA), 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 is optional, a fully completed Form WH-

381 provides employees with the information required by 29 C.F.R. §§ 825.300(b), (c) which must be provided with in five

business days of the employee notifying the employer of the need for FMLA leave. Information about the FMLA may be

found on the WHD website at www.dol.gov/agencies/whd/fmla.

Date: ___________________________ (mm/dd/yyyy)

From: ___________________________________ (Employer) To: ______________________________________ (Employee)

On __________________ (mm/dd/yyyy), we learned that you need leave (beginning on) _____________________ (mm/dd/yyyy)

for one of the following reasons: (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

newly-placed child

Your own serious health condition

You are needed to care for your family member due to a serious health condition. Your family member is your:

SpouseParentChild under age 18  Child 18 years or older and incapable of self-

care because of a mental or physical disability

A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of

an impending call or order to covered active duty status. Your family member on covered active duty is your:

SpouseParentChild of any age

You are needed to care for your family me mber who is a covered servicemember with a serious injury or illness. You

are the servicemember’s:

SpouseParentChildNext of kin

Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in a common law

marriage or same-sex marriage. 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 to care for an individual who assumed the obligations of a parent

to the employee when the e mployee was a child. An employee may also take FMLA leave to care for a child for whom the employee

has assumed the obligations of a parent. No legal or biological relationship is necessary.

SECTION I – NOTICE OF ELIGIBILITY

This Notice is to inform you that you are:

Eligible for FMLA leave. (See Section II for any Additional Information Needed and Section III for information on your Rights

and Responsibilities.)

Not eligible for FMLA leave because: (Only one reason need be checked)

You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave,

you will have worked approximately: __________ towards this requirement.

(months)

You have not met the FMLA’s 1,250 hours of service requirement. As of the first date of requested leave, you

will have worked approximately: _______________towards this requirement.

(hours of service)

Page 1 of 4 Form WH-381, Revised June 2020