Intermittent FMLA is leave taken pursuant to the Family Medical Leave Act (FMLA) for a single injury, taken in separate, non-consecutive time periods rather than a single span of time. Family and Medical Leave (FMLA) The Family and Medical Leave Act (FMLA) provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.
The Department has developed optional-use forms which can be used by employers to provide required notices to employees, and by employees to provide certification of their need for leave for an FMLA qualifying reason. These forms are electronically fillable PDFs and can be saved electronically. Alternatively, Employers may use their own forms, if they provide the same basic notice information and require only the same basic certification information.
Notice Forms
Employers covered by the FMLA are obligated to provide their employees with certain critical notices about the FMLA so that both the employees and the employer have a shared understanding of the terms of the FMLA leave. For more information on satisfying the FMLA’s employer notification requirements, see WHD Fact Sheet # 28D: Employer Notification Requirements under the Family and Medical Leave Act.
Employers can use the following forms to provide the notices required under the FMLA.
- General Notice, the FMLA poster – satisfies the requirement that every covered employer display or post an informative general notice about the FMLA. This notice can also be used by employers with eligible employees to satisfy their obligation also to provide FMLA general notice to employees in written leave guidance (e.g., handbook) or individually upon hire.
- Eligibility Notice, form WH-381 – informs the employee of his or her eligibility for FMLA leave or at least one reason why the employee is not eligible.
- Rights and Responsibilities Notice, form WH-381 (combined with the Eligibility Notice) – informs the employee of the specific expectations and obligations associated with the FMLA leave request and the consequences of failure to meet those obligations.
- Designation Notice, form WH-382 – informs the employee whether the FMLA leave request is approved; also informs the employee of the amount of leave that is designated and counted against the employee’s FMLA entitlement. An employer may also use this form to inform the employee that the certification is incomplete or insufficient and additional information is needed.
Certification Forms
Certification is an optional tool provided by the FMLA for employers to use to request information to support certain FMLA-qualifying reasons for leave. An employee can provide the required information contained on a certification form in any format, such as on the letterhead of the healthcare provider, or official documentation issued by the military.
Please do not send any completed certification forms to the U.S. Department of Labor, Wage and Hour Division. Return completed certifications to the employee to provide to his or her employer.
Occasional Fmla Benefits
There are five DOL optional-use FMLA certification forms.
Certification of Healthcare Provider for a Serious Health Condition
Examples Of Intermittent Fmla Leave
- 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.
Certification of Military Family Leave
Occasional Fmla Rules
- 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.
Fmla Intermittent Leave Form Letter
Questions and Answers About FMLA Forms
Fmla Intermittent Leave Request Form
- The Department revised the optional-use FMLA forms in June 2020. Can I still use the old DOL forms?
Yes. The FMLA does not require the use of any specific form or format. Although the Department revised the FMLA forms in June 2020 to make them easier to understand for employers, leave administrators, healthcare providers, and employees seeking leave, the revised forms convey and collect the same information, which can be provided in any format.
- Can my employer require me to provide a new certification, using the revised form, when I have already provided the required FMLA information using the old certification form?
No. You can provide the required information contained on a certification form in any format. If you used the old certification forms to provide your employer with the required FMLA information, you do not have to provide your employer with the same FMLA information using the revised certification forms.
- Can my employer make changes to the FMLA forms?
Your employer may use the WHD prototype forms or create their own version of the forms containing the same basic information. However, an employer that requests a medical certification may request only information that relates to the serious health condition for which the current need for leave exists, and no information may be required beyond that specified in the FMLA regulations. See 29 CFR 825.306, 29 CFR 825.307, and 29 CFR 825.308.
- Do I have to use my employer’s certification forms?
Employers must accept a complete and sufficient certification, regardless of the format. The employer cannot reject a certification that contains all the information needed to determine if the leave is FMLA-qualifying. The employer cannot refuse:
- A fax or copy of the certification;
- A certification that is not completed on the employer’s standard company form; or
- Any other record of the medical documentation, such as a communication on the letterhead of the healthcare provider.
- The expiration date of the DOL forms has passed, are they still effective?
Yes. The content of the information contained within the optional-use DOL form is still applicable, regardless of the expiration date. The expiration date on the DOL forms is related to the collection of information as required by the Office of Management and Budget (OMB), and not relevant to the content of the required information.
- Where do I send the completed certifications or notices?
Do not send any completed certifications or forms to the U.S. Department of Labor, Wage and Hour Division. The employer should provide the required notices to the employee seeking leave. Completed certification forms should be given to the employee to provide to the employer, as it is the employee’s responsibility to provide the employer with the completed certification.
- Do these forms have any applicability to the Families First Coronavirus Response Act (FFCRA)?
No. The FFCRA has different documentation requirements which can be found at 29 CFR 826.100 or www.dol.gov/agencies/whd/pandemic/ffcra-questions. Please see question & answer items #15 and #16 for more information.