29 CFR Part 825, The Family and Medical Leave Act of 1993

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form WH-382 Notice to Employee of FMLA Leave Designation	Form and Instruction	New	Available
Form WH-381 Notice to Employees of FMLA Eligibility	Form and Instruction	Modified	Available
Form WH-380 Medical Certifications and Recertifications	Form and Instruction	Modified	Available
1215-0181PreambleSS(20080205).doc	Supplementary Document	Uploaded 2008-02-05	Available
1215-0181 Note to the Reviewer(20080124).doc	Supplementary Document	Uploaded 2008-01-24	Available
1215-0181ssOMB(20080131).doc	Supporting Statement A	Uploaded 2008-01-31	Available
Proposed Part 825 Regulations with PRA Implications(20080114).doc	Supplementary Document	Uploaded 2008-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
182234	Notice to Employee of Pending Cancellation of Health Benefits		New
182233	Documenting Family Relationships		New
182083	Periodic Employee Status Report		New
182081	Notice to Employee of FMLA Leave Designation	Form and Instruction	New
178656	General Recordkeeping		Modified
178655	Key Employee Notifications		Modified
178654	Fitness-For-Duty Medical Certifications		Modified
178653	Notice to Employees of Change of 12-Month Period for Determining Entitlement		Modified
178608	Written Guidance to Employees of FMLA Rights (Handbooks/Manuals)		Removed
178607	Employee Notice of Need for FMLA Leave		Modified
178568	Notice to Employees of FMLA Eligibility	Form and Instruction	Modified
13897	Medical Certifications and Recertifications	Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0181	ICR Reference No: 200709-1215-004
Status: Historical Inactive	Previous ICR Reference No: 200702-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: 29 CFR Part 825, The Family and Medical Leave Act of 1993
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 03/11/2008
	Date Received in OIRA: 02/11/2008
Terms of Clearance: Terms of the previous clearance remain in effect. OMB is filing comment on this ICR, which is part of a proposed rule. Approval is not granted at this time. DOL should resubmit this ICR in conjunction with the final rule.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	36 Months From Approved	09/30/2010
Responses	15,058,850	0	15,058,850
Time Burden (Hours)	1,370,288	0	1,370,288
Cost Burden (Dollars)	11,915,480	0	11,915,480

---

Abstract: The Family and Medical Leave Act of 1993 (FMLA), 29 U.S.C. § 2601, et seq., requires private sector employers of 50 or more employees and public agencies to provide up to 12 weeks of unpaid, job-protected leave during any 12-month period to “eligible” employees for certain family and medical reasons (i.e., for birth of a son or daughter, and to care for the newborn child; for placement with the employee of a son or daughter for adoption or foster care; to care for the employee’s spouse, son, daughter, or parent with a serious health condition; and because of a serious health condition that makes the employee unable to perform the functions of the employee’s job). FMLA section 404 requires the Secretary of Labor to prescribe such regulations as necessary to enforce this Act. 29 U.S.C. § 2654.

---

Authorizing Statute(s): US Code: 29 USC 2601, et seq Name of Law: Family and Medical Leave Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1215-AB35	Proposed rulemaking	73 FR 7875	02/11/2008

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
Written Guidance to Employees of FMLA Rights (Handbooks/Manuals)
Notice to Employee of Pending Cancellation of Health Benefits
Notice to Employee of FMLA Leave Designation	WH-382	Notice to Employee of FMLA Leave Designation
Documenting Family Relationships
Employee Notice of Need for FMLA Leave
Fitness-For-Duty Medical Certifications
Key Employee Notifications
General Recordkeeping
Notice to Employees of Change of 12-Month Period for Determining Entitlement
Medical Certifications and Recertifications	WH-380	Certification of Health Care Provider (Family and Medical Leave Act)
Notice to Employees of FMLA Eligibility	WH-381	Eligibility Notice (Family and Medical Leave Act)
Periodic Employee Status Report

---

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: Compared to the last OMB clearance of the FMLA information collections on September 20, 2007, this request reflects an overall burden increase of 8,223,197 hours, of which 5,798,666 result from proposed regulatory changes. In addition, this request reflects 56,019,788 additional responses, of which 25,571,988 stem from proposed regulatory changes; and increased maintenance and operations costs of $95,302,207, with the proposed regulatory changes accounting for a $924,760 increase. The changed paperwork burden estimates stem from (1) the fact that prior efforts to calculate burden often used aggregate totals per respondent and did not break out each individual third-party disclosure or recordkeeping activity; (2) increased wages rates for persons completing the information collections and other higher costs, as discussed in Items 12-14 of the supporting statement; (3) a reconsideration of whether certain regulations impose a burden beyond what employees and employers customarily would do were the regulations not to exist, (4) additions to and deletions from specific notification requirements, and (5) improved information on the number of respondents subject to the FMLA paperwork requirements.

---

Annual Cost to Federal Government: $634,950

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/11/2008

---