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FMLA Notice of Eligibility and Rights: Notice of Eligibility & Rights and Responsibilities under the Family and Medical Leave Act
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Form WH-381 in short
Form WH-381 is the Department of Labor's optional notice an employer gives to an employee who asks for FMLA leave. It tells the employee whether they are eligible for FMLA leave, what extra information is needed, and their rights and responsibilities while on leave. The employer completes it and gives it to the employee.
| Issued by | U.S. Department of Labor, Wage and Hour Division (WHD) |
|---|---|
| Current version | Revised June 2020 (checked 2026-10-25) |
| Who fills it in | A covered employer, after an employee asks for leave or the employer learns that the leave may be for an FMLA reason. |
| Who receives it | The employee who asked for the leave. The form says not to send it to the Department of Labor. |
| Where to send it | The employer gives it to the employee and keeps a copy. Do not send it to the Department of Labor. |
| Deadline | The form says the information must be provided within five business days of the employee notifying the employer of the need for FMLA leave. Employers must keep a copy for three years. |
| Official links | Official page · Official PDF |
How to fill out Form WH-381, line by line
| Page 1, header | Date, employer, employee and leave start Enter the date of the notice, the employer and employee names, the date the employer learned of the need for leave and when the leave begins. |
| Page 1, reason for leave | Reason for leave Select the reason: birth or placement of a child, the employee's own serious health condition, care for a family member, a military qualifying exigency, or care for a covered servicemember. Select the family relationship where asked. |
| Section I | Notice of eligibility Check eligible or not eligible. If not eligible, check one reason, such as fewer than 12 months of service, fewer than 1,250 hours of service, the airline flight crew requirements, or no site with 50 or more employees within 75 miles. |
| Section II | Additional information needed Say whether a certification is required and which type, whether it is attached, and the return date, which must allow at least 15 calendar days. You can also ask for proof of the family relationship. |
| Section III, Part A | FMLA leave entitlement Choose how the 12-month leave period is calculated: calendar year, fixed leave year, forward from first use, or rolling backward. Also state whether the employee is a key employee. |
| Section III, Part B | Substitution of paid leave Check whether leave will be unpaid, whether the employee asked to use paid leave, or whether the employer requires paid leave to run at the same time, and give the conditions. |
| Section III, Parts C to F | Health benefits, other benefits, return to work and other requirements Give contacts for paying health insurance premiums, the premium grace period, and whether periodic status reports are required and how often. |
Common mistakes to avoid
- Giving the notice later than five business days after the employee tells the employer they need FMLA leave.
- Checking more than one reason for not being eligible. The form says only one reason needs to be checked.
- Setting a certification return date less than 15 calendar days away.
- Not choosing a method for the 12-month leave period in Section III, Part A.
- Leaving the premium payment contact and grace period blank in Part C.
- Sending the notice to the Department of Labor instead of giving it to the employee.
- Using WH-381 to approve or deny the leave. That is done with the Designation Notice, Form WH-382.
Questions about Form WH-381
Who completes Form WH-381?
The employer. It is a notice from the employer to the employee about eligibility for FMLA leave and the employee's rights and responsibilities.
What are the FMLA eligibility rules shown on the form?
In general, the employee must have worked for the employer for at least 12 months, have at least 1,250 hours of service in the 12 months before the leave, and work at a site with at least 50 employees within 75 miles. Airline flight crews have special hours rules.
Is WH-381 the same as the designation notice?
No. WH-381 covers eligibility and rights and responsibilities. Form WH-382 tells the employee whether the leave is approved as FMLA leave and how much will be counted.
Does the employer have to use this exact form?
No. The Department of Labor's forms are optional. An employer may use its own form if it gives the same basic notice information.
How much FMLA leave can an employee take?
Up to 12 workweeks of unpaid, job-protected leave in a 12-month period for most FMLA reasons, and up to 26 workweeks in a single 12-month period for military caregiver leave.
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Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the U.S. Department of Labor, Wage and Hour Division or any government agency. This page is general information, not legal or tax advice.