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Form WH-381: Notice of Eligibility and Rights and Responsibilities (FMLA)
Employer notice to an employee of FMLA eligibility status and their rights and responsibilities under FMLA. Employers must provide this notice within 5 business days of receiving a leave request.
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DOL Form WH-381 - Notice of Eligibility and Rights and Responsibilities (FMLA)
Employer notice to an employee of FMLA eligibility status and their rights and responsibilities under FMLA. Employers must provide this notice within 5 business days of receiving a leave request.
Risk Radar
Scan points- 1Employer not providing the notice within 5 business days — this may prevent the employer from counting the leave against FMLA entitlement.
- 2Employee not noting the certification deadline — failure to return certification can result in leave denial.
- 3Employee not understanding the requirement to use accrued paid leave concurrently with FMLA.
Plain English
This is the form your employer gives you when you request FMLA leave. It tells you whether you are eligible and what your rights and responsibilities are.
Submission Date
- Filing date: Employer must provide within 5 business days of receiving notice that leave may be FMLA-qualifying.
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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Field map
Compact field-by-field guide
Employee Info
1 items
Employee's name.
Eligibility
2 items
Whether the employee is eligible for FMLA leave.
If ineligible, the specific reason.
Leave Details
3 items
The FMLA-qualifying reason for leave.
Whether medical certification is required.
Deadline for returning certification forms.
Paid Leave
1 items
Which accrued paid leave must be used concurrently.
Signature
1 items
HR representative's name and title.
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