(Family and Medical Leave Act)
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
OMB Control Number: 1215-0181
Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform the employee of the
amount of leave that will be counted against the employee’s FMLA leave entitlement. In order to determine whether leave is covered under the FMLA, the
employer may request that the leave be supported by a certification. If the certification is incomplete or insufficient, the employer must state in writing what
additional information is necessary to make the certification complete and sufficient. While use of this form by employers is optional, a fully completed Form
H-382 provides an easy method of providing employees with the written information required by 29 C.F.R. §§ 825.300(c), 825.301, and 825.305(c).
We have reviewed your request for leave under the FMLA and any supporting documentation that you have provided.
We received your most recent information on
_____ Your FMLA leave request is approved. All leave taken for this reason will be designated as FMLA leave.
The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were
initially unknown. Based on the information you have provided to date, we are providing the following information about the
amount of time that will be counted against your leave entitlement:
_____ Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will be
counted against your leave entitlement: _____________________________________________
_____ Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or weeks that will be counted