Fillable Printable Form WH-384

Form WH-384

Page 1 CONTINUED ON NEXT PAGE WH-384 R evised February 2013

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: 5/31/2018

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.

Empl

oyer 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 N

ame: _______________________________________________________________________________________

First Middle Last

Name of military member on covered active duty or call to covered active duty status:

__________________________________________________________________________________________________

First Middle Last

Rel

ationship of military member to you: ___________________________________________________________

Peri

od 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 2 CONTINUED ON NEXT PAGE WH-384 R evised 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 3 WH-384 Revised February 2013

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 PUB LIC BURDEN ST ATEMENT

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 S-3502, 200

Constitution AV, NW, Washington, DC 20210. DO N OT SEND THE CO MPLETED FORM TO THE WAGE AND HOUR DIVISION;

RETURN IT TO THE EMPLOYER.