Fill out Form WH-381 online

Who uses Form WH-381

• Employers covered by the FMLA answering an employee's request for leave
• HR staff and leave administrators who prepare FMLA notices
• Employees who receive the notice and want to understand what it says

Before you start

• The date you learned the employee needs leave and the date the leave is to begin
• The reason for the leave and, if it involves a family member, how they are related to the employee
• How many months the employee has worked for you and about how many hours they worked in the 12 months before the leave (airline flight crew have special hours rules)
• Whether the employee's worksite has 50 or more employees within 75 miles
• How you count the FMLA 12-month period, whether the employee is a key employee, your paid leave policy and how health premiums are paid during leave
• Names and contact details of the people the employee should contact with questions

How to fill out Form WH-381

1. 1

   Page 1 opening: date, names and reason for leave

   Enter the date of the notice, the employer's and the employee's names, the date you learned the employee needs leave, and the date the leave begins. Check the reason for leave. For a family member's health condition, a qualifying exigency or military caregiver leave, also check the family member's relationship to the employee.

2. 2

   Section I – Notice of Eligibility

   Check whether the employee is eligible for FMLA leave. If not, check at least one reason (only one is needed): the 12-month length of service requirement (enter the approximate months worked), the 1,250 hours of service requirement (enter the approximate hours), the special hours rules for airline flight crew employees, or the 50 employees within 75 miles requirement. Enter the name and contact information of the employer representative for questions.

3. 3

   Section II – Additional Information Needed

   This section is for an eligible employee. Check that no additional information is requested, or request a certification and mark its type (health care provider for the employee, health care provider for a family member, qualifying exigency, or military caregiver leave) and whether the certification form is attached. Enter the return date, which must allow at least 15 calendar days from your request. You can also ask for documentation or a statement of the family relationship and for other information, each with its own due date. Enter a contact for questions.

4. 4

   Section III, Part A – FMLA Leave Entitlement

   Check how the 12-month period is calculated: the calendar year, a fixed leave year (describe it), forward from the first FMLA leave use, or a rolling period measured backward. If military caregiver leave applies, enter the date its single 12-month period started. Mark whether the employee is a key employee and whether you have determined that restoring them would cause substantial and grievous economic harm.

5. 5

   Section III, Part B – Substitution of Paid Leave

   Check all that apply: some or all of the leave is unpaid, the employee asked to use paid leave, you require the use of paid leave, or other (for example short- or long-term disability, workers' compensation or a state medical leave law). Enter the conditions for using paid leave and where the employee can find the paid leave policy.

6. 6

   Section III, Parts C and D – Health and other benefits

   In Part C, enter who the employee contacts, and how, to arrange their share of health insurance premiums during unpaid leave, and mark the grace period for premium payments (30 days or a longer period you enter). In Part D, enter who to contact about continuing other employee benefits during leave.

7. 7

   Section III, Parts E and F – Return to work and reports

   Part E explains job restoration rights and has nothing to fill in. In Part F, mark whether the employee must send periodic reports of their status and intent to return to work, and enter how often. Part F also tells the employee to give at least two workdays' notice before returning early. Enter the employee's name at the top of pages 2, 3 and 4.

After you fill it out

The employer gives the completed notice to the employee; it is not sent to the Department of Labor. The notice is due within five business days after the employee asks for leave or the employer learns the leave may be for an FMLA-qualifying reason. The rights and responsibilities part must be in writing and may be given electronically if all other notice rules are met. The employer must keep a copy in its records for three years.

Signing: The form has no signature line. The employer completes it and gives it to the employee.

Questions about Form WH-381

Official information

• FMLA forms (U.S. Department of Labor)
• Fact Sheet #28D: Employer Notification Requirements under the FMLA
• Family and Medical Leave Act (Wage and Hour Division)

Page text last reviewed November 7, 2026.

Related forms

• Form WH-380-ECertification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act
• Form WH-380-FCertification of Health Care Provider for Family Member’s Serious Health Condition under the Family and Medical Leave Act