Notice of Eligibility and Rights & Responsibilities Wage and Hour Division (Family and Medical Leave Act)

The Notice of Eligibility and Rights & Responsibilities form is divided into two main parts: 1) Rights and Responsibilities for taking FMLA Leave. 2) notice of eligibility

Extracted Text for Proper Search

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Notice of Eligibility and Rights &  U.S. Department of Labor
Responsibilities 		Wage and Hour Division 	
(Family and Medical Leave Act) 	_ 	OMB Control Number: 1235-0003 
Expires: 2/28/2015	
In general, to be eligible 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 by employers  is optional, a 
fully completed Form WH-381 provides employees with the information required by 29 C.F.R. § 825.300(b), which must be provided within 
five business days of the employee notifying the employer of the need for FMLA leave. Part B provides employees with informatio n 
regarding their rights and responsibilities for taking FM LA leave, as required by 29 C.F.R. § 825.300(b), (c).  
[Part A – NOTICE OF ELIGIBILITY ] 
TO:  	 _________ ____________
___________________ 
Employee 
FROM: _________ _______________________________    Employer Representative 
DATE: _________ ________________________ ___

____ 
On _____________________,  you informed us that you needed leave beginning on 
_______________________ for: 
_____	 The birth of a child, or placement of a child with you for adoption or foster care;  
_____	 Your own serious health condition;  
_____	 Because y

ou are needed to care for your  ____   spouse;  _____child;   ______  parent due to his/her serious health condition . 
_____	 Because of a qualify ing exigency

 arising out of the fact that your ____  spouse;  _____son or daughter;   ______ parent is on covered 
active duty  or call to 

covered active duty status with the Armed Forces. 
_____ 	Beca

use you are the ____   spouse; _____son or daughter;  ______ parent; _______  next of kin  of a covered service	

member wi th a 
serious injury  o	
r illness. 
This Notice is t	
o infor m	

 you that you: 
_____	 Are eligible for FMLA leave (S ee Part B below
 for Rights and Respon	

sibilities) 
_____	  Are not eligible for FMLA leave, because (only one reason need be check ed, although you may not be eligible for other reasons):     
_____	 You have not  met the FMLA’s 
12-m
onth lengt
h of service requi rem
ent.  As of the first date o f requested leave, you will 
have worked ap proxi

mately

 ___ months  towards this requirement.  

_____  You have not met the FMLA’s hours of service  require	

ment.   

_____  You do not work and/or report to a site with 50 or more employees within 75-miles. 
	
  If you have any questions , contact ___________________________________________________  or view the 
FMLA poster located in  _________________________________________________________________________. 
[PART B-RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE
] 
As  explained in  Part A, you  meet the eligibilit y requirements  for taking F MLA leav e an d  still have FMLA  l eave  available i n the  applica	ble 
12-m	 onth period .  However, in order for us  to determine whether your	
  absence qualifies as FMLA  leave, you mu st return the 
following information to us by ____________________	

_______________. (If a certification is requested, em ployers mu	

st allow at least 15 
calendar days from receipt of this notice; a	

dditional time may be required in some circum sta	

nces.) If sufficient information is not provided in 
a timely manner, your leave may be denied. 	
____	 Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to suport your   
request ____is/ ____ is not  enclosed. 
____	 Sufficient documentation to establish the require d relationship between you and your family member. 
____	 Other information needed (such as documentation for military family leave):  _______________________________________________________ _ 
____  No additional information requested 
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