Department of Budget and Management

Family and Medical Leave Act Guide (PDF) (Revised June/2018) - This booklet contains information on FMLA including a description of the program, definitions of terms, eligibility information, information on how the program works and what to do if you need to use Family and Medical Leave.

New Forms​

Certification of Healthcare Provider for a Serious Health Condition
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• Employee’s serious health condition, form WH-380-E (PDF) – use when a leave request is due to the medical condition of the employee.
• Family member’s serious health condition, form WH-380-F (PDF) – use when a leave request is due to the medical condition of the employee’s family member.
• Help for health care providers – This flier guides healthcare providers through FMLA rules concerning medical certifications. It’s a handy tool that medical professionals can use to make sure patients’ and family caregivers’ employment is protected as they deal with serious health conditions.
• Notice of Eligibility and Right & Responsibility, form WH381 (PDF) - This form is sent with the initial FMLA request with the 15 calendar day deadline.
• Designation Notice WH382 (PDF) - This form is sent after the approval email.
• Return to Work Form (PDF)

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Certification of Military Family Leave
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• Qualifying Exigency, form WH-384 (PDF) – use when the leave request arises out of the foreign deployment of the employee’s spouse, son, daughter, or parent.
• Military Caregiver Leave of a Current Servicemember, form WH-385 (PDF) – use when requesting leave to care for a family member who is a current service member with a serious injury or illness.
• Military Caregiver Leave of a Veteran, form WH-385-V (PDF) – use when requesting leave to care for a family member is who a covered veteran with a serious injury or illness.

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