The WH-384 form, officially titled "Certification of Qualifying Exigency For Military Family Leave," serves a crucial role under the U.S. Department of Labor's Wage and Hour Division for implementing provisions of the Family and Medical Leave Act (FMLA). This form enables employees who have loved ones on covered active military duty to apply for FMLA leave for "qualifying exigencies." These exigencies cover a broad range of needs, from making financial and legal arrangements to attending counseling sessions, thus recognizing the unique pressures military families face. Employers are instructed to complete a section of the form to verify their compliance with FMLA requirements, ensuring they do not demand more information than the regulations allow. Meanwhile, employees are responsible for providing detailed information about the exigency, the relationship to the military member, the period of the military member's active duty, and specific needs that the leave will address. Documentation to confirm the military member's status and the nature of the qualifying exigency is also required, reinforcing the form's role in substantiating leave requests. By facilitating this process, the WH-384 form stands as a testament to the value placed on supporting military families while balancing the operational needs of employers.
| Question | Answer |
|---|---|
| Form Name | Form Wh 384 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | WH 384 wh 384 2009 form |
Certification of Qualifying Exigency |
U.S. Department of Labor |
For Military Family Leave |
Wage and Hour Division |
(Family and Medical Leave Act) |
|
OMB Control Number:
Expires: 2/ 28/2015
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a qualifying exigency to submit a certification. Please complete Section I before giving this form to your employee. Your response is voluntary, and while you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 CFR 825.309.
Employer name: ____________________________________________________________________________________
Contact Information: _________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II fully and completely. The FMLA permits an employer to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a qualifying exigency. Several questions in this section seek a response as to the frequency or duration of the qualifying exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Your response is required to obtain a benefit. 29 CFR 825.310. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at least 15 calendar days to return this form to your employer.
Your Name: _______________________________________________________________________________________
First |
Middle |
Last |
Name of military member on covered active duty or call to covered active duty status:
__________________________________________________________________________________________________
FirstMiddleLast
Relationship of military member to you: ___________________________________________________________
Period of military member’s covered active duty: __________________________________________________________
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a military member’s covered active duty or call to covered active duty status. Please check one of the following and attach the indicated document to support that the military member is on covered active duty or call to covered active duty status.
A copy of the military member’s covered active duty orders is attached.
Other documentation from the military certifying that the military member is on covered active duty (or has been notified of an impending call to covered active duty) is attached.
I have previously provided my employer with sufficient written documentation confirming the military member’s covered active duty or call to covered active duty status.
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PART A: QUALIFYING REASON FOR LEAVE
1.Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you are requesting leave):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2.A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes any available written documentation which supports the need for leave; such documentation may include a copy of a meeting announcement for informational briefings sponsored by the military; a document confirming the military member’s Rest and Recuperation leave; a document confirming an appointment with a third party, such as a counselor or school official, or staff at a care facility; or a copy of a bill for services for the handling of legal or financial affairs. Available written documentation supporting this request for leave is attached.
Yes |
No |
None Available |
PART B: AMOUNT OF LEAVE NEEDED
1.Approximate date exigency commenced: __________________________________________________________
Probable duration of exigency: __________________________________________________________________
2.Will you need to be absent from work for a single continuous period of time due to the qualifying exigency? Yes No
If so, estimate the beginning and ending dates for the period of absence:
___________________________________________________________________________________________
3. Will you need to be absent from work periodically to address this qualifying exigency? Yes No
Estimate schedule of leave, including the dates of any scheduled meetings or appointments:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time (i.e., 1
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours ___ day(s) per event.
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PART C:
If leave is requested to meet with a third party (such as to arrange for childcare or parental care, to attend counseling, to attend meetings with school, childcare or parental care providers, to make financial or legal arrangements, to act as the military member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and sufficient certification includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either the telephone or fax number or email address of the individual or entity). This information may be used by your employer to verify that the information contained on this form is accurate.
Name of Individual: ______________________________ Title: ______________________________________________
Organization: ______________________________________________________________________________________
Address: __________________________________________________________________________________________
Telephone: (________) ___________________________ Fax: (_______) ______________________________________
Email: ____________________________________________________________________________________________
Describe nature of meeting: ___________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PART D:
I certify that the information I provided above is true and correct.
Signature of Employee ___________________________________________ Date _______________________________
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. 2616; 29 CFR 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. T he Department of Labor estimates that it will take an average of 20 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
RETURN IT TO THE EMPLOYER.
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