Information Collection

Medical Certifications and Recertifications

IC 13897 under ICR 200702-1215-001 · OMB 1215-0181.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0181 can be found here:

Documents and Forms

Document Name Document Type
Form WH-380 Medical Certifications and Recertifications Form and Instruction
WH-380 Certication of Health Care Provider (FMLA) wh380.pdf www.dol.gov/esa/regs/compliance/whd/fmla/wh380.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Certifications and Recertifications	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 825.305 29 CFR 825.307 29 CFR 825.308 29 CFR 825.306

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	WH-380	Certication of Health Care Provider (FMLA)	wh380.pdf	http://www.dol.gov/esa/regs/compliance/whd/fmla/wh380.pdf	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,909,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,909,000	-13,148,750	15,057,750
Annual IC Time Burden (Hours)	636,333	-733,770	1,370,103
Annual IC Cost Burden (Dollars)	11,301,280	11,301,280	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.