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.                                                                       OMB Control Number: 1235-0003 
 PROVIDE TO EMPLOYEE.                                                                                                    Expires: 6/30/202 6 
 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 within 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 member        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 employee 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 

Employee Name: ____________________________________________________________________________________________ 

           You are an airline flight crew employee and you have not met the           special hours of service eligibility       requirements 
            for airline flight crew     employees as of the first date of requested leave (i.e., worked or      been paid for     at least 60% 
            of your applicable monthly guarantee, and worked or been paid for at least  504 duty hours.) 

           You do not work   at and/or       report to a site with 50 or more employees within 75-miles as   of the date of your 
            request. 

  If you have any questions, please contact: ________________________________________ (Name of employer  representative)  
at  _________________________________________________________________________________________________ (Contact information).  

                            SECTION II – ADDITIONAL INFORMATION NEEDED  
As explained in Section I, you         meet the eligibility requirements for taking FMLA leave. Please review the information                      
below to determine if additional information is needed in order for us to determine whether your absence qualifies as FMLA 
leave. Once we obtain any additional information specified below we will inform           you,   within 5 business days              , whether 
your leave will be designated as FMLA leave and count towards the FMLA leave you have available.                        If complete and 
sufficient information is not provided   in a timely manner, your         leave may be denied.   
(Select as appropriate) 

    No additional information requested. If no additional  information requested, go to Section III. 

    We request  that the leave be supported by a certification, as identified below. 
       Health Care Provider for        the Employee               Health Care Provider for the Employee’s Family Member 
       Qualifying Exigency                                        Serious Illness or Injury (Military Caregiver Leave) 
     Selected certification form is attached /   not attached. 

     If requested, medical certification must be returned by ______________________ (mm/dd/yyyy) (Must allow at least 15 
     calendar days from the date the employer requested the employee to provide certification, unless it is not  feasible despite the employee’s  
     diligent,  good faith efforts.)  

     We request that you provide reasonable documentation or a         statement to establish the relationship between you and 
     your family member, including         in loco parentis relationships (as explained on page one). The information             requested        
     must be returned to us by ____________________            (mm/dd/yyyy). You may choose to provide   a simple statement   of the 
     relationship or provide documentation such as a        child’s birth certificate, a court document, or documents regarding                    
     foster care or adoption-related activities. Official documents submitted for this purpose will  be returned to you after  
     examination.   

    Other information needed  (e.g. documentation for military family leave): ________________________________. 
     The information requested must be returned to us  by _____________________ (mm/dd/yyyy). 

  If you have any questions, please contact: ________________________________________ (Name of employer representative)  
  at __________________________________________________________________________ (Contact information). 

                        SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES 
Part A: FMLA Leave Entitlement 
You have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family and 
medical reasons, including up to        12 weeks of unpaid leave in a 12-month period for the birth of a child or       placement of a             
child for adoption or foster care, for leave related to your own or a family member’s          serious          health condition, or for          certain 
qualifying exigencies related to the deployment of a military member to covered active duty. You also have a right  

Page 2 of 4                                                                                        Form WH-381, Revised June                      2020 

Employee Name: ____________________________________________________________________________________________ 
                                                                                                                                                             
under the FMLA to take up to     26 weeks of unpaid, job-protected FMLA leave in a single 12-month period to care for a                                      
covered servicemember with a serious injury or illness (Military  Caregiver Leave).    
 
The 12-month period for FMLA leave is calculated as: (Select as appropriate) 
 
        The calendar year (January 1 st-                     December 31st)                 
 
           A fixed leave year based on _____________________________________________________________   
                                                             (e.g., a fiscal year beginning on July 1 and ending on June 30)  
 
        The 12-month period measured forward from the date                                 of your   first FMLA leave     usage. 
 
           A “rolling” 12-month period measured backward from the date of any FMLA leave usage. (Each time an employee 
           takes FMLA leave, the remaining leave is the balance of the 12 weeks                            not used during the 12 months immediately before  
           the FMLA leave is  to start.)  
 
If applicable, the single 12-month period forMilitary Caregiver Leave started on ______________________ (mm/dd/yyyy).   
 
You ( are /    are not) considered              a key employee              as defined under the FMLA. Your FMLA leave cannot be denied for 
this reason; however,    we may not  restore  you  to employment following FMLA leave  if                                    such  restoration will cause    
substantial and grievous economic injury to us.                        
 
We ( have /     have not) determined that restoring you to employment at the                                 conclusion of FMLA leave    will cause      
substantial and grievous economic harm to us. Additional information will be provided separately concerning                                     your status 
as key employee and restoration. 
 
Part B: Substitution of Paid Leave – When                             Paid Leave is Used       at the Same Time as FMLA            Leave   
You have a right under the FMLA                   to request        that your     accrued paid leave be substituted for your FMLA          leave. This means 
that you can request that your accrued paid leave run concurrently with some or all of your unpaid FMLA leave, provided 
you meet any applicable requirements of our                         leave policy.  Concurrent leave use means the absence will count against both 
the designated paid leave and unpaid FMLA leave at the same time. If   you do not meet the requirements for taking                                   paid 
leave, you remain entitled to   take available unpaid FMLA leave in the                             applicable 12-month period. Even if          you do not  
request it, the FMLA allows us to require you to use your available sick, vacation, or other                                 paid leave during your FMLA     
absence.   
 
(Check all that apply) 
 
   Some or all of your FMLA leave will                       not be paid.         Any unpaid FMLA leave taken will be designated as              FMLA   
    leave and counted against the amount of FMLA leave you have available to use in                                 the applicable 12-month period. 
     
   You have requested to use some or all of                            your available paid leave           (e.g., sick, vacation, PTO)  during your FMLA 
    leave. Any paid leave taken for this reason will also be designated as FMLA leave and counted against the amount of                                      
    FMLA leave you have available to use in                           the applicable 12-month period. 
     
   We are requiring you to use some or all of                          your available paid leave (e.g., sick, vacation, PTO) during your FMLA 
    leave.Any   paid leave taken for this reason will                        also be designated as FMLA leave and counted against          the amount of 
    FMLA leave you have available to use in the applicable 12-month period.                                  
     
   Other: (e.g., short- or long-term disability, workers’ compensation, state medical leave law, etc.)_________________________  
    Any time taken for this      reason will also be designated as FMLA leave and                                   counted against the amount of            
    FMLA leave you have available to use in the applicable 12-month period.  
 
The applicable conditions  for use of paid leave include: ____________________________________________________.  
 
For more information about conditions applicable to sick/vacation/other                               paid leave usage please refer to _____________  
 
__________________________________________ available at: ____________________________________________. 
 
Page 3 of 4                                                                                                                 Form WH-381, Revised June  2020 

Employee Name: ____________________________________________________________________________________________ 
 
Part C: Maintain Health Benefits 
Your health benefits must be maintained during any period of FMLA leave under the same conditions as if you continued 
to work. During any paid portion of FMLA  leave, your share of any premiums will be paid by the method normally used                     
during any paid leave. During any unpaid portion of FMLA leave, you must continue to make any normal contributions to 
the cost of the health insurance premiums.     To make arrangements to continue      to make your share of the premium payments 
on your health  insurance       while you are on any unpaid  FMLA  leave,        contact  ____________________________  at 
_____________________________________. 
  
You have a minimum grace period of (         30-days or  _____________ indicate longer period, if applicable) in which to 
make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify 
you in writing at least 15 days before   the date that your health coverage will     lapse, or, at our option, we may pay your share 
of the premiums during FMLA leave, and recover these payments from you upon your return to work.                    
 
You may be required to reimburse us for our share of  health insurance premiums paid on your behalf during your FMLA 
leave if you do not return to work following unpaid FMLA leave for a reason other than: the continuation, recurrence, or 
onset of your or your family member’s     serious health condition which would entitle          you to FMLA leave; or    the continuation, 
recurrence, or onset of a covered servicemember’ s serious injury or illness which would entitle you to FMLA leave; or                    
other circumstances beyond your control. 
       
Part D: Other Employee Benefits 
Upon your return from FMLA leave, your other employee benefits, such as pensions or                life insurance, must be resumed in 
the same manner and at the same levels as provided when your FMLA leave began. To make arrangements                      to continue 
your employee benefits while you are on FMLA leave, contact _______________________________________________ 
at _________________________________________________. 
 
Part E: Return-to-Work Requirements 
You must be reinstated   to the same or an    equivalent  job with  the same pay, benefits,     and terms and conditions        of employment 
on your return from FMLA-protected leave. An equivalent position is one that is virtually identical to your              former position 
in terms of pay, benefits, and working conditions. At the end of your FMLA leave, all benefits must             also be resumed in the 
same manner and at the same level provided when the leave began. You do not have return-to-work rights under the FMLA 
if you need leave beyond the amount of FMLA leave you have available to use. 
 
Part F: Other Requirements While on           FMLA Leave 
 
While on leave you ( will be /    will not be) required   to furnish us with periodic reports of your status and intent to 
return  to work every ________________________________________________________________________________. 
                                    (Indicate interval of periodic reports, as appropriate for the FMLA leave situation)      . 
 
         If the circumstances of your leave change and you are able to return   towork earlier              than expected,          
       you will be required to notify us at least two       workdays prior to the date you         intend to report   for work. 
 
                   PAPERWORK REDUCTION ACT NOTICE AND                          PUBLIC BURDEN STATEMENT                   
It is mandatory for employers to provide employees        with notice of their eligibility  for FMLA protection and their rights and      
responsibilities. 29 U.S.C. § 2617; 29 C.F.R. § 825.300(b), (c). It is mandatory for employers to retain a copy of this disclosure in their 
records for three years. 29 U.S.C.  § 2616; 29 C.F.R. § 825.500. Persons  are not required to respond to this collection of information 
unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 10 minutes  
for respondents to complete this collection of information, including the time for reviewing instructions, searching existing   data sources, 
gathering and maintaining the data needed, and completing and reviewing the collection of information. If you   have       any comments 
regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send  
them to the   Administrator, Wage and Hour Division, U.S. Department of  Labor,    Room  S-3502,    200 Constitution  Avenue, N.W., 
Washington, D.C. 20210. 
__________________________________________________________________________________________________________________________________________________________________________________________________  
 DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF LABOR. EMPLOYEE INFORMATION. 
 
Page 4 of 4                                                                                            Form WH-381, Revised June      2020