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 * WHD
 * Family and Medical Leave Act
 * FMLA: Forms


FMLA: FORMS




The Department has developed optional-use forms which can be used by employers
to provide required notices to employees, and by employees to provide
certification of their need for leave for an FMLA qualifying reason. These forms
are electronically fillable PDFs and can be saved electronically. Alternatively,
employers may use their own forms, if they provide the same basic notice
information and require only the same basic certification information.


NOTICE FORMS

Employers covered by the FMLA are obligated to provide their employees with
certain critical notices about the FMLA so that both the employees and the
employer have a shared understanding of the terms of the FMLA leave. For more
information on satisfying the FMLA’s employer notification requirements, see WHD
Fact Sheet # 28D: Employer Notification Requirements under the Family and
Medical Leave Act.

Employers can use the following forms to provide the notices required under the
FMLA.

 1. General Notice, the FMLA poster – satisfies the requirement that every
    covered employer display or post an informative general notice about the
    FMLA. This notice can also be used by employers with eligible employees to
    satisfy their obligation also to provide FMLA general notice to employees in
    written leave guidance (e.g., handbook) or individually upon hire.
 2. Eligibility Notice, form WH-381 (Spanish) – informs the employee of his or
    her eligibility for FMLA leave or at least one reason why the employee is
    not eligible.
 3. Rights and Responsibilities Notice, form WH-381 (Spanish) (combined with the
    Eligibility Notice) – informs the employee of the specific expectations and
    obligations associated with the FMLA leave request and the consequences of
    failure to meet those obligations.
 4. Designation Notice, form WH-382 (Spanish) – informs the employee whether the
    FMLA leave request is approved; also informs the employee of the amount of
    leave that is designated and counted against the employee’s FMLA
    entitlement. An employer may also use this form to inform the employee that
    the certification is incomplete or insufficient and additional information
    is needed.


CERTIFICATION FORMS

Certification is an optional tool provided by the FMLA for employers to use to
request information to support certain FMLA-qualifying reasons for leave. An
employee can provide the required information contained on a certification form
in any format, such as on the letterhead of the healthcare provider, or official
documentation issued by the military.

Please do not send any completed certification forms to the U.S. Department of
Labor, Wage and Hour Division. Return completed certifications to the employee
to provide to his or her employer.

There are five DOL optional-use FMLA certification forms.

Certification of Healthcare Provider for a Serious Health Condition

 * Employee’s serious health condition, form WH-380-E (Spanish) - Use when a
   leave request is due to the medical condition of the employee.
 * Family member’s serious health condition, form WH-380-F (Spanish) - Use when
   a leave request is due to the medical condition of the employee’s family
   member.
 * Help for health care providers – This flier guides healthcare providers
   through FMLA rules concerning medical certifications. It’s a handy tool that
   medical professionals can use to make sure patients’ and family caregivers’
   employment is protected as they deal with serious health conditions. 

Certification of Military Family Leave

 * Qualifying Exigency, form WH-384 (Spanish) – use when the leave request
   arises out of the foreign deployment of the employee’s spouse, son, daughter,
   or parent.
 * Military Caregiver Leave of a Current Servicemember, form WH-385 (Spanish) –
   use when requesting leave to care for a family member who is a current
   service member with a serious injury or illness.
 * Military Caregiver Leave of a Veteran, form WH-385-V (Spanish) – use when
   requesting leave to care for a family member is who a covered veteran with a
   serious injury or illness.


QUESTIONS AND ANSWERS ABOUT FMLA FORMS

 1. Can my employer make changes to the FMLA forms?
    
    Your employer may use the WHD prototype forms or create their own version of
    the forms containing the same basic information. However, an employer that
    requests a medical certification may request only information that relates
    to the serious health condition for which the current need for leave exists,
    and no information may be required beyond that specified in the FMLA
    regulations. See 29 CFR 825.306(link is external), 29 CFR 825.307(link is
    external), and 29 CFR 825.308(link is external).

 2. Do I have to use my employer’s certification forms?
    
    Employers must accept a complete and sufficient certification, regardless of
    the format. The employer cannot reject a certification that contains all the
    information needed to determine if the leave is FMLA-qualifying. The
    employer cannot refuse:
    
    * A fax or copy of the certification;
    * A certification that is not completed on the employer’s standard company
      form; or
    * Any other record of the medical documentation, such as a communication on
      the letterhead of the healthcare provider.

 3. The expiration date of the DOL forms has passed, are they still effective?
    
    Yes. The content of the information contained within the optional-use DOL
    form is still applicable, regardless of the expiration date. The expiration
    date on the DOL forms is related to the collection of information as
    required by the Office of Management and Budget (OMB), and not relevant to
    the content of the required information.

 4. Where do I send the completed certifications or notices?
    
    Do not send any completed certifications or forms to the U.S. Department of
    Labor, Wage and Hour Division. The employer should provide the required
    notices to the employee seeking leave. Completed certification forms should
    be given to the employee to provide to the employer, as it is the employee’s
    responsibility to provide the employer with the completed certification.

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