Department of Budget and Management

Family and Medical Leave Act Guide (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​

• Employee’s serious health condition, form WH-380-E – use when a leave request is due to the medical condition of the employee.
• Family member’s serious health condition, form WH-380-F ​– 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 - This form is sent with the initial FMLA request with the 15 calendar day deadline
• Designation Notice WH382​  - This form is sent after the approval email.
• Return to Work Form 

Certification of Military Family Leave​

• Qualifying Exigency, form WH-384 – 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 – 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 – use when requesting leave to care for a family member is who a covered veteran with a serious injury or illness.​