Information Collection Request

29 C.F.R. Part 825, The Family and Medical Leave Act of 1993

ICR 201003-1235-003 · OMB 1235-0003 · Historical Active

Forms and Documents

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
187163 Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal) New
187079 Notice to Employee of Pending Cancellation of Health Benefits (Federal) New
187078 Notice to Employee of FMLA Designation (Federal) Form and Instruction NewDesignation Notice (Family and Medical Leave Act)
187073 Key Employee Notification (Federal) New
186957 Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal) New
186955 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction NewNotice of Eligibility and Rights & Responsibilities
186913 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction NewNotice of Eligibility and Rights & Responsibilities
186900 Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal) New
186899 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction NewDesignation Notice (Family and Medical Leave Act)
186898 General FMLA Recordkeeping (Federal) New
186891 Key Employee Notification (State, local, tribal) New
186890 General FMLA Recordkeeping (State, local, tribal) New
182234 Notice to Employee of Pending Cancellation of Health Benefits (Private Sector) Modified
182233 Documenting Family Relationship Modified
182083 Periodic Employee Status Report Modified
182081 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction ModifiedDesignation Notice (Family and Medical Leave Act)
178656 General FMLA Recordkeeping (Private Sector) Modified
178655 Key Employee Notification (Private Sector) Modified
178654 Fitness-For-Duty Medical Certifications Removed
178653 Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector) Modified
178608 Written Guidance to Employees of FMLA Rights (Handbooks/Manuals) Removed
178607 Employee's Notice of Need for FMLA Leave Modified
178568 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction ModifiedNotice of Eligibility and Rights & Responsibilities
13897 Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy Form and Instruction ModifiedCertification for Serious Injury or Illness of Covered Servicemember--for Military Family Leave (Family and Medical Leave Act)
13897 Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy Form and Instruction ModifiedCertification of Qualifying Exigency For Military Family Leave
13897 Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy Form and Instruction ModifiedCertification of Health Care Provider for Family Member�s Serious Health Condition
13897 Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy Form and Instruction ModifiedCertification of Health Care Provider for Employee�s Serious Health Condition

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
12/31/2011 36 Months From Approved
88,385,575 0 15,058,850
18,969,645 0 1,370,288
162,821,810 0 11,915,480





Reginfo record details
22
table that charts list of burden
IC Title Form No. Form Name
Documenting Family Relationship
Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy WH-380-F, WH-384, WH-385, WH-380-E ,   ,   ,  
Employee's Notice of Need for FMLA Leave
Fitness-For-Duty Medical Certifications
General FMLA Recordkeeping (State, local, tribal)
General FMLA Recordkeeping (Federal)
General FMLA Recordkeeping (Private Sector)
Key Employee Notification (Federal)
Key Employee Notification (Private Sector)
Key Employee Notification (State, local, tribal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Designation (Federal) WH-382
Notice to Employee of FMLA Designation (Private Sector) WH-382
Notice to Employee of FMLA Designation (State, local, tribal) WH-382
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) WH-381
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) WH-381
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) WH-381
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Periodic Employee Status Report
Written Guidance to Employees of FMLA Rights (Handbooks/Manuals)

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 88,385,575 15,058,850 14,827,012 4,669 58,495,044 0
Annual Time Burden (Hours) 18,969,645 1,370,288 3,482,473 7,020,126 7,096,758 0
Annual Cost Burden (Dollars) 162,821,810 11,915,480 455,927 0 150,450,403 0


Reginfo record details
  No