Fillable Certification for Military Family Leave for U.S. Department (City of Brockton, MA)

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Certification for Military Family Leave for U.S. Department (City of Brockton, MA)

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Certification for Military Family Leave for U.S. Department of Labor
Qualifying Exigency Wage and Hour Division
under the Family and Medical Leave Act
Page 1 of 4 Form WH-384, Revised June 2020
________________________________________________________________________________________________________________________
DO NOT SEND FORM TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003
RETURN THE COMPLETED FORM TO THE EMPLOYER. Expires: 6/30/2023
________________________________________________________________________________________________________________________________________________________________________________________________________________________
The Family and Medical Leave Act (FMLA) provides that eligible employees may take FMLA leave for a qualifying
exigency while the employee's spouse, child, or parent (the military member) is on covered active duty or has been notified
of an impending call or order to covered active duty. The FMLA allows an employer to require an employee seeking FMLA
leave due to a qualifying exigency to submit a certification. 29 U.S.C. §§ 2613, 2614(c)(3). The employer must give the
employee at least 15 calendar days to provide the certification. 29 C.F.R. § 825.305(b). If the employee fails to provide
complete and sufficient certification, the employee’s FMLA leave request may be denied. 29 C.F.R. § 825.313. Information
about the FMLA may be found on the WHD website at http://www.dol.gov/agencies/whd/fmla
.
SECTION I - EMPLOYER
Either the employee or the employer may complete Section I. While use of this form is optional, it asks the employee for
the information necessary for a complete and sufficient qualifying exigency certification, which is set out at 29 C.F.R. §
825.309. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29
C.F.R. § 825.309.
(1) Empl
oyee name: ________________________________________________________________________
First Middle Last
(2) Employer name: __________________________________________ Date: _____________________ (mm/dd/yyyy)
(List date certification requested)
(3) This certification must be returned by_____________________________________________________________ (mm/dd/yyyy).
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s diligent, good faith efforts.)
SECTION II - EMPLOYEE
Please complete all Parts of Section II and sign the form before returning it to your employer. The FMLA allows 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. If requested by your employer, your response is required to obtain the benefits and protections of the
FMLA. 29 C.F.R. § 825.309. Failure to provide a complete and sufficient certification may result in a denial of your FMLA
leave request. 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.
You are responsible for making sure the certification is provided to your employer within the time frame requested,
which must be at least 15 calendar days. 29 C.F.R. § 825.313.
(1) Pro
vide the name of the military member on covered active duty or call to covered active duty status:
__________________________________________________________________________________________
First Middle Last
(2) Select your relationship of the military member. The military member is your:
Spouse Parent Child, of any age
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including a common
law marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which a person
assumes the obligations of a parent to a child. An employee may take FMLA leave for a qualifying exigency related a military
member who assumed the obligations of a parent to the employee when the employee was a child. An employee may also take
FMLA leave for a qualifying exigency related a military member for whom the employee has assumed the obligations of a
parent. No legal or biological relationship is necessary.
Employee Name: ___________________________________________________________________________________________
Page 2 of 4 For
m WH-384, Revised June 2020
PART A: COVERED ACTIVE DUTY STATUS
Covered active duty or call to covered active duty in the case of a member of the Regular Armed Forces means duty during
the deployment of the member with the Armed Forces to a foreign country. Covered active duty or call to covered active
duty in the case of a member of the Reserve components means duty during the deployment of the member with the Armed
Forces to a foreign country under a Federal call or order to active duty in support of a contingency operation pursuant to:
Section 688 of Title 10 of the United States Code; Section 12301(a) of Title 10 of the United States Code; Section 12302
of Title 10 of the United States Code; Section 12304 of Title 10 of the United States Code; Section 12305 of Title 10 of
the United States Code; Section 12406 of Title 10 of the United States Code; chapter 15 of Title 10 of the United States
Code; or, any other provision of law during a war or during a national emergency declared by the President or Congress
so long as it is in support of a contingency operation. 10 U.S.C. § 101(a)(13)(B).
An empl
oyer may require the employee to provide a copy of the military member's active duty orders or other
documentation issued by the military which indicates that the military member is on covered active duty or call to covered
active duty status, and the dates of the military member's covered active duty service. This information need only be
provided to the employer once, unless additional leave is needed for a different military member or different
deployment.
(3) Prov
ide the dates of the military member’s covered active duty service: __________________________________
(4) Please ch
eck one of the following and attach the indicated written 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
Other
documentation from the military indicating that the military member is on covered active duty or has
been notified of an impending call to covered active duty, such as official military correspondence from the
military member’s chain of command
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
PART B: APPROPRIATE FACTS
Under the FMLA, leave can be taken for a number of qualifying exigencies. 29 C.F.R. § 825.126(b). Complete and
sufficient certification to support a request for FMLA leave due to a qualifying exigency includes available written
documentation which supports the need for leave such as a copy of a meeting announcement for informational briefings
sponsored by the military, a document confirming the military member’s Rest and Recuperation leave, or other
documentation issued by the military which indicates that the military member has been granted Rest and Recuperation
leave, or a document confirming an appointment with a third party (e.g., a counselor or school official, or staff at a care
facility, a copy of a bill for services for the handling of legal or financial affairs). Please provide appropriate facts related
to the particular qualifying exigency to support the FMLA leave request, including information on the type of qualifying
exigency and any available written documentation of the exigency event.
(5) Select the appropriate Qualifying Exigency Category and, if needed, provide additional information related to
the event:
Short notice deployment (i.e., deployment within seven or fewer days of notice)
Military events and related activities
(e.g., official ceremonies or events, or family support and assistance programs):
_________________________________________________________________________________________________
Childc
are related activities for the child of the military member
(e.g., arranging for alternative childcare):
____________________________________________________________________________________________________________
Employee Name: ___________________________________________________________________________________________
Page 3 of 4 For
m WH-384, Revised June 2020
Care for the military member’s parent (e.g., admitting or transferring the parent to a new care facility):
____________________________________________________________________________________________________________
Financial and legal arrangements related to the deployment
(e.g., obtaining military identification cards)
Counseling related to the deployment (i.e., counseling provided by someone other than a health care provider)
Military member’s short-term, temporary Rest and Recuperation leave (R&R) (leave for this reason is limited
to 15 calendar days for each instance of R&R)
Post deployment activities
(e.g., arrival ceremonies, or reintegration briefings and events):________________________
____________________________________________________________________________________________________________
Any other event that the employee and employer agree is a qualifying exigency: _______________________
____________________________________________________________________________________________________________
(6) Available written documentation supporting this request for leave is ( attached / not attached / not
available).
PART C: AMOUNT OF LEAVE NEEDED
Provide information concerning the amount of leave that will be needed. Several questions in this section seek a
response as to the frequency or duration of the qualifying exigency leave needed. Be as specific as you can; terms such as
“unknown” or “indeterminate” may not be sufficient to determine FMLA coverage.
(7) List the approximate date exigency started or will start: _________________________________________ (mm/dd/yyyy)
(8) Provide your best estimate of how long the exigency lasted or will last:
From __________________________________ (mm/dd/yyyy) to ____________________________________ (mm/dd/yyyy)
(9) Due to a qualifying exigency, I need to work a reduced schedule. Provide your best estimate of the reduced
schedule you are able to work:
From __________________________________ (mm/dd/yyyy) to ____________________________________ (mm/dd/yyyy)
I am able to work _______________________________________________________________________________
(
e.g., 5 hours/day, up to 25 hours a week)
(10)
Due to a qualifying exigency, I will need to be absent from work for a continuous period of time. Provide your
best estimate of the beginning and ending dates for the period of absence:
From _________________________________ (mm/dd/yyyy) to ____________________________________ (mm/dd/yyyy)
Employee Name: ___________________________________________________________________________________________
Page 4 of 4 Fo
rm WH-384, Revised June 2020
(11) Due to a qualifying exigency, I will need to be absent from work on an intermittent basis (periodically).
Provide your best estimate of the frequency (how often) and duration (how long) of each appointment, meeting, or
leave event, including any travel time.
Over the next 6 months, absences on an int
ermittent basis are estimated to occur: _______________ times per
( day / week / month) and are likely to last approximately
_____________ ( hours / days) per episode.
(12) My leave is due to a qualifying exigency that involves Rest and Recuperation leave (R & R) of the military
member (leave for this reason is limited to 15 calendar days for each instance of R & R leave).
List t
he dates of the military member’s R &R leave:
From ___________________________________ (mm/dd/yyyy) to ___________________________________ (mm/dd/yyyy)
PART D: THIRD PARTY INFORMATION
If applicable, please provide information below that may be used by your employer to verify meetings or appointments with
a third party related to the qualifying exigency. Examples of meetings with third parties include: arranging for childcare or
parental care, to attend non-medical 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. This information may be used by your employer to verify that the information contained
on this form is accurate.
Individual (e.g., name and title) or Entity / Organization: _____________________________________________________
Address: __________________________________________________________________________________________
Telephone: (___) ________________ Fax: (___) ________________ E-mail: ___________________________________
Describe purpose of meeting: __________________________________________________________________________
Employee
Signature _______________________________________________________________ Date ________________
(mm/dd/yyyy)
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 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number. The Department of Labor estimates that it will take an average of 15 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 Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF DEPARTMENT OF LABOR.
RETURN FORM TO THE EMPLOYER.
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Certification for Military Family Leave for U.S. Department (City of Brockton, MA)

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Completed 31 January 2021

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