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FMLA Designation Notice

FMLA Designation Notice

FMLA Designation Notice

29 CFR §825.300(d) • Comparable to DOL Form WH-382 • Family and Medical Leave Act of 1993

This Designation Notice is issued pursuant to the Family and Medical Leave Act of 1993 (FMLA), 29 U.S.C. §2601–2654, and the implementing regulations at 29 CFR Part 825. It informs the employee identified below whether leave requested or taken is designated as FMLA-qualifying, and sets forth the terms, conditions, and requirements associated with that designation.

Date of Notice: [Notice Date]

Section 1 – Employer Information

SECTION 1 – EMPLOYER INFORMATION

Employer / Company: [Employer Name]

Address: [Employer Address], [City], [State] [ZIP]

HR Representative: [HR Representative]

HR Phone: [HR Phone]

HR Email: [HR Email]

Section 2 – Employee Information

SECTION 2 – EMPLOYEE INFORMATION

Employee Name: [Employee Name]

Job Title / Position: [Job Title]

Department: [Department]

Section 3 – FMLA Eligibility Determination

SECTION 3 – FMLA ELIGIBILITY DETERMINATION

Employee FMLA-Eligible: [Employee Eligible]

If Not Eligible — Reason: [Ineligibility Reason]

FMLA eligibility is determined based on the criteria at 29 U.S.C. §2611(2): the employee must have been employed by this employer for a total of at least 12 months, must have worked at least 1,250 hours of service during the 12-month period immediately preceding the commencement of the leave, and must work at a location where the employer employs 50 or more employees within 75 miles.

If the employee is not yet eligible due to insufficient months of employment but will become eligible within 26 weeks of the date leave is requested, the employer must provide notice of the date on which the employee becomes eligible and the employee may take qualifying leave on or after that date.

Section 4 – Leave Designation

SECTION 4 – LEAVE DESIGNATION

Leave Designated as FMLA-Qualifying: [Leave Designated]

If Not Qualifying — Reason: [Non-Qualifying Reason]

FMLA Qualifying Reason: [Qualifying Reason]

Under 29 CFR §825.300(d)(1), the employer is required to provide this Designation Notice within five business days of having enough information to determine whether the leave qualifies as FMLA leave, absent extenuating circumstances. Once leave is designated as FMLA leave, the employer must notify the employee of the designation in writing.

If the employer does not have sufficient information to determine whether leave qualifies, the employer must notify the employee of the additional information needed (29 CFR §825.303(c)). An employer may not retroactively designate leave as FMLA leave without the employee’s agreement to retroactive designation, except as provided in 29 CFR §825.301(d).

Section 5 – Designated Leave Period and Entitlement

SECTION 5 – DESIGNATED LEAVE PERIOD AND FMLA ENTITLEMENT

Designated Leave Start Date: [Leave Start Date]

Designated Leave End Date: [Leave End Date]

Amount of FMLA Leave Counted: [FMLA Amount Counted]

Remaining FMLA Balance After This Leave: [Remaining Balance]

12-Month Period Calculation Method: [12-Month Period Method]

Under 29 U.S.C. §2612(a)(1), eligible employees are entitled to a total of 12 workweeks of FMLA leave during any applicable 12-month period for most qualifying reasons. Under 29 U.S.C. §2612(a)(3), eligible employees are entitled to up to 26 workweeks of leave during a single 12-month period to care for a covered servicemember with a serious injury or illness. Leave entitlement is not restored when the leave year resets if taken for military caregiver purposes.

Section 6 – Leave Schedule

SECTION 6 – LEAVE SCHEDULE

Type of FMLA Leave: [Leave Schedule Type]

If intermittent leave is designated, the employee is required to follow the employer’s usual and customary call-in procedures for reporting each absence, unless prevented by a medical emergency (29 CFR §825.303). The employee must make a reasonable effort to schedule foreseeable intermittent leave to minimize disruption to employer operations (29 CFR §825.302(e)).

If the employer requires the employee to transfer temporarily to an alternative position that better accommodates a reduced or intermittent schedule, that position must have equivalent pay and benefits (29 CFR §825.204). The employer may not reduce the employee’s pay below their regular rate.

Section 7 – Substitution of Paid Leave

SECTION 7 – SUBSTITUTION OF ACCRUED PAID LEAVE

Employer Requiring Paid Leave Substitution: [Paid Leave Required]

Paid Leave Type(s) Required: [Paid Leave Type]

FMLA leave is unpaid by operation of federal law. However, under 29 CFR §825.207, the employer may require — and the employee may elect — to substitute accrued paid vacation, personal, sick, or PTO leave for any part of the FMLA leave period. When paid leave is substituted, it runs concurrently with FMLA leave; it does not extend the total FMLA entitlement.

If the employer requires substitution of paid leave, it must follow the terms and conditions of its existing paid leave policy, including any requirements for providing documentation or notice. The employer may not impose additional conditions on the substitution that do not apply to non-FMLA leaves of absence.

Section 8 – Additional Requirements

SECTION 8 – ADDITIONAL REQUIREMENTS DURING FMLA LEAVE

Periodic Status Reports Required: [Status Reports Required]

Frequency and Method of Status Reports: [Status Report Frequency]

Fitness-for-Duty Certification Required Upon Return: [Fitness Cert Required]

Fitness-for-Duty Certification Details: [Fitness Cert Details]

The employer’s requirements for status reports during leave must be consistent with its policies for other types of medical leave (29 CFR §825.311). If the employer requires a fitness-for-duty certification before reinstating the employee, it must notify the employee of that requirement in this Designation Notice. Failure to provide this notice precludes the employer from delaying or denying reinstatement based on the absence of a fitness-for-duty certification (29 CFR §825.300(d)(3)).

Section 9 – Employee Rights During and After FMLA Leave

SECTION 9 – EMPLOYEE RIGHTS DURING AND AFTER FMLA LEAVE

The employee is advised of the following rights under the Family and Medical Leave Act while on FMLA-designated leave and upon return:

  • Group health plan coverage must be maintained during FMLA leave under the same terms and conditions as if the employee had continued to work (29 U.S.C. §2614(c)). The employee remains responsible for their share of premium payments.
  • The employee is entitled to be reinstated to the same position upon return from FMLA leave, or to an equivalent position with equivalent pay, benefits, and other terms and conditions (29 U.S.C. §2614(a)).
  • Retaliation against an employee for exercising FMLA rights is prohibited under 29 U.S.C. §2615. The use of FMLA leave may not be counted under a no-fault attendance policy or used as a negative factor in hiring, promotions, or disciplinary actions.
  • Benefits that accrued prior to the FMLA leave must be restored upon return. Benefits do not continue to accrue during unpaid FMLA leave unless the employer’s policy provides otherwise.
  • Key employees (top 10% by salary within 75 miles) may be denied reinstatement if necessary to prevent substantial and grievous economic injury to the employer. If this exception applies, the employer will provide separate written notice of the employee’s key employee status (29 CFR §825.218).
  • Employees who believe their FMLA rights have been violated may file a complaint with the Wage and Hour Division of the U.S. Department of Labor or file a private lawsuit in federal or state court within 2 years (or 3 years if the violation was willful) under 29 U.S.C. §2617.

Section 10 – Employer Authorization

SECTION 10 – EMPLOYER AUTHORIZATION

This FMLA Designation Notice is issued on behalf of [Employer Name] by the authorized HR representative identified below. This notice does not constitute a waiver of any rights the employer may have under the FMLA or any other applicable federal, state, or local law.

Employer: [Employer Name]

HR Representative: [HR Representative]

Date: [Notice Date]

Signature of HR Representative: _______________________________ Date: _______________

EMPLOYEE ACKNOWLEDGMENT (Optional)

I, [Employee Name], acknowledge receipt of this FMLA Designation Notice. I understand the rights and responsibilities described herein.

Employee Signature: _______________________________ Date: _______________

Note: Employee acknowledgment is optional. The employer’s FMLA obligations are not contingent upon the employee signing this form.

Applicant

________________

Signature

Date: ________________

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What Is a FMLA Designation Notice?

A FMLA Designation Notice in the United States gives formal notice of the sender's position or demand and the action required of the recipient.

Under 29 CFR §825.300(d), the employer must provide a written Designation Notice within five business days after it has sufficient information to determine whether the leave qualifies as FMLA leave. This timing obligation runs from the point when the employer has enough facts — the employee's leave request, the qualifying reason stated, any medical certification — to make the FMLA determination. Absent extenuating circumstances, missing the five-day window creates compliance exposure.

The Designation Notice is equivalent to DOL Form WH-382, the official Department of Labor form employers may use for this purpose. However, employers are not required to use the DOL form — any written notice that conveys the required information satisfies the regulatory requirement.

What makes the Designation Notice strategically important for employers is that it defines the terms of the FMLA relationship going forward. It states how much leave is being counted against the employee's entitlement, how the 12-month period is calculated (calendar year, fiscal year, rolling backward, or forward from first use), whether paid leave substitution is required, whether periodic status reports are expected, and — critically — whether a fitness-for-duty certification will be required before the employee can return to their position.

For employees, the Designation Notice is equally important because it confirms job protection and sets expectations for the leave period. An employee who has not received a Designation Notice may be uncertain about their legal status and whether their job is protected. Under 29 CFR §825.300(e), if the employer fails to provide notice of a requirement — such as fitness-for-duty certification — in a timely Designation Notice, the employer cannot use the absence of that certification to delay or deny reinstatement.

When Do You Need a FMLA Designation Notice?

The Designation Notice is needed any time an employer determines, or reasonably should determine, that an employee's absence or leave request may qualify under FMLA. The employer's obligation to designate is not optional — it attaches when the facts cross the threshold, even if the employee does not specifically invoke the Act, and even if the employer would prefer not to designate the leave.

The five-day clock for issuing the Designation Notice starts running when the employer has enough information. This typically follows the Eligibility Notice (which must also be issued within five business days) and, where medical certification is required, the receipt of completed certification. However, if the employer already has enough information without waiting for certification — for instance, the employee has stated that they need six weeks of leave for chemotherapy starting next month — the employer should issue the Designation Notice as soon as the eligibility determination is made.

A common scenario requiring a Designation Notice is when an employee has already been absent for several days due to illness and the employer recognizes, retrospectively, that the absence was FMLA-qualifying. Under 29 CFR §825.301(d), retroactive designation is generally permitted if the employer's failure to designate was due to not having sufficient information at the time of the absence. The Designation Notice should specify the retroactive start date and the total leave counted.

Another important scenario involves intermittent leave. When an employee is approved for intermittent FMLA leave for a chronic condition — migraine headaches, Crohn's disease, a mental health condition requiring periodic treatment — the Designation Notice formally approves that arrangement and sets the parameters: the eligible period, the entitlement cap, and the call-in requirements for each episode.

Employers of highly compensated key employees — those in the top 10% of salary within 75 miles of the worksite — may deny reinstatement if necessary to prevent substantial and grievous economic injury. If this exception may apply, the employer must notify the employee in writing of their key employee status and the potential consequences as early as practicable, ideally in the Designation Notice itself, so the employee can make an informed decision about whether to take leave.

What to Include in Your FMLA Designation Notice

A legally compliant FMLA Designation Notice addresses every element required by 29 CFR §825.300(d) and provides the employee with a clear, complete picture of their FMLA status.

The notice opens with identifying information — the employer's name, address, HR contact, and the date the notice is issued. The date is critical for establishing the five-day compliance window and for creating a paper trail if the designation is later disputed.

The eligibility determination tells the employee whether they meet the three-part test of 29 U.S.C. §2611(2). If the employee is not eligible, the notice must explain which requirement is not met. If the employee will become eligible within 26 weeks, the notice should indicate when that eligibility date arrives.

The leave designation itself answers the central question: is this leave FMLA-protected? The notice states yes or no and, if yes, identifies the qualifying reason from 29 U.S.C. §2612(a)(1). If no, the notice explains why the leave does not qualify — the condition is not a serious health condition, the family member does not qualify as a covered family member, or the reason falls outside the statutory categories.

The leave period section specifies the start and end dates of the designated period and, crucially, the amount being counted against the employee's entitlement. It also states the 12-month period calculation method the employer uses. Employers must apply one method consistently to all employees; they cannot switch methods mid-stream or apply different methods to different groups of employees.

Paid leave substitution terms clarify whether the employee will be paid during any part of the FMLA leave through substitution of accrued vacation, sick, or PTO balances. Employers have the right to require substitution consistent with their existing paid leave policies — but they must state that requirement in the Designation Notice.

The additional requirements section gives the employer the opportunity to specify any conditions that apply during the leave: periodic reporting obligations, how the employee should communicate status updates, and most importantly, whether fitness-for-duty certification will be required before reinstatement. Failing to notify the employee of the fitness-for-duty requirement in the Designation Notice bars the employer from enforcing that requirement when the employee attempts to return.

Finally, the employee rights summary ensures the employee understands that their job, health coverage, and accumulated benefits are protected during FMLA leave, and that retaliation for exercising FMLA rights is unlawful.

Sources & Citations

Statutory citations link to official government sources.

  1. 29 U.S.C. §2611US – Cornell LII
  2. 29 U.S.C. §2612US – Cornell LII
  3. 29 CFR §825.300US – eCFR
  4. 29 CFR §825.301US – eCFR
  5. FMLAUS – Cornell LII

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Reference this free template in an article, syllabus, or research note:

APA

Forms Legal. (2026). FMLA Designation Notice (United States) [Legal document template]. Forms Legal. https://forms-legal.com/usa/employment/forms/fmla-designation-notice

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BibTeX
@misc{formslegal-fmla-designation-notice,
  author       = {{Forms Legal}},
  title        = {FMLA Designation Notice (United States)},
  year         = {2026},
  howpublished = {\url{https://forms-legal.com/usa/employment/forms/fmla-designation-notice}},
  note         = {Free legal document template. Based on Family and Medical Leave Act (29 U.S.C. §2601)}
}

Frequently Asked Questions

Based on Family and Medical Leave Act (29 U.S.C. §2601) — Template last modified June 2026Verify the source →

This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer

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