Information Collection

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

IC 13897 under ICR 201003-1235-003 · OMB 1235-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1235-0003 can be found here:

Documents and Forms

Document Name Document Type
Form WH-380-E 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
WH-380-E Certification of Health Care Provider for Employee�s Ser WH-380-E(2008).doc www.dol.gov/esa/whd/forms/wh-380-E.pdf Form and Instruction
WH-380-F Certification of Health Care Provider for Family Member� WH-380-F(2008).doc www.dol.gov/esa/whd/forms/wh-380-F.pdf Form and Instruction
WH-384 Certification of Qualifying Exigency For Military Family WH-384(2008).doc www.dol.gov/esa/whd/forms/wh-384.pdf Form and Instruction
WH-385 Certification for Serious Injury or Illness of Covered S WH-385(2008).doc www.dol.gov/esa/whd/forms/wh-385.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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	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 825.306 29 CFR 825.305 29 CFR 825.100(d) 29 CFR 825.308 29 CFR 825.307 29 CFR 825.213(a)(3) 29 CFR 825.216(b) 29 CFR 825.310 29 CFR 825.312 29 CFR 825.309

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-E	Certification of Health Care Provider for Employeeï¿½s Serious Health Condition	WH-380-E(2008).doc	http://www.dol.gov/esa/whd/forms/wh-380-E.pdf	Yes	Yes	Fillable Printable
Form and Instruction	WH-380-F	Certification of Health Care Provider for Family Memberï¿½s Serious Health Condition	WH-380-F(2008).doc	http://www.dol.gov/esa/whd/forms/wh-380-F.pdf	Yes	Yes	Fillable Printable
Form and Instruction	WH-384	Certification of Qualifying Exigency For Military Family Leave	WH-384(2008).doc	http://www.dol.gov/esa/whd/forms/wh-384.pdf	Yes	Yes	Fillable Printable
Form and Instruction	WH-385	Certification for Serious Injury or Illness of Covered Servicemember--for Military Family Leave (Family and Medical Leave Act)	WH-385(2008).doc	http://www.dol.gov/esa/whd/forms/wh-385.pdf	Yes	Yes	Fillable Printable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,454,097	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12,080,153	1,443,572	0	8,727,581	1,909,000
Annual IC Time Burden (Hours)	4,009,851	464,324	0	2,909,194	636,333
Annual IC Cost Burden (Dollars)	162,821,810	455,927	3,501,720	147,562,883	11,301,280

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.