Form Wh 384 – Fill Out and Use This PDF

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: 1235-0003

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.

Page 1

CONTINUED ON NEXT PAGE

WH-384 Revised February 2013

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 deployment-related meeting every month lasting 4 hours):

Frequency: _____ times per _____ week(s) _____ month(s)

Duration: _____ hours ___ day(s) per event.

Page 2

CONTINUED ON NEXT PAGE

WH-384 Reeised February 2013