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Get DoL WH-381 2020-2024

If you have any questions please do not hesitate to contact 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. Serious injury or illness. This Notice is to inform you that you Are eligible for FMLA leave See Part B below for Rights and Responsibilities Are not eligible for FMLA leave because only one reason need be checked although you may not be eligible for other reasons You have not met the FMLA s 12-month length of service requirement. Notice of Eligibility and Rights Responsibilities Family and Medical Leave Act U.S. Department of Labor Wage and Hour Division 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. Part B provides employees with information regarding their rights and responsibilities for taking FMLA leave as required by 29 C. F.R. 825. 300 b c. Part A NOTICE OF ELIGIBILITY TO Employee FROM Employer Representative DATE The birth of a child or placement of a child with you for adoption or foster care Your own serious health condition Because you are needed to care for your spouse child parent due to his/her serious health condition. Because of a qualifying 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. You do not work and/or report to a site with 50 or more employees within 75-miles. If you have any questions contact 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 leave and still have FMLA leave available in the applicable 12-month period. However in order for us to determine whether your absence qualifies as FMLA leave you must return the following information to us by. If a certification is requested employers must allow at least 15 calendar days from receipt of this notice additional time may be required in some circumstances. 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 information regarding their rights and responsibilities for taking FMLA leave as required by 29 C. F*R* 825. 300 b c. Part A NOTICE OF ELIGIBILITY TO Employee FROM Employer Representative DATE The birth of a child or placement of a child with you for adoption or foster care Your own serious health condition Because you are needed to care for your spouse child parent due to his/her serious health condition* Because of a qualifying 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.

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