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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.