Employment Information Form

ICR 201003-1235-021

OMB: 1235-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
0000-00-00
IC Document Collections
IC ID
Document
Title
Status
13616 Modified
ICR Details
1235-0021 201003-1235-021
Historical Active 200404-1215-003
DOL/WHD
Employment Information Form
Extension without change of a currently approved collection   No
Regular
Approved without change 06/06/2007
Retrieve Notice of Action (NOA) 03/28/2007
  Inventory as of this Action Requested Previously Approved
06/30/2010 36 Months From Approved
35,000 0 35,000
11,667 0 11,667
0 0 0

Form WH-3 is an optional form complainants (e.g., current and former employees, unions, and, competitor employers) may use to provide information about alleged violations of the labor standards administered by the Wage and Hour Division (WHD) of the U.S. Department of Labor. Complaints themselves or WHD staff, using information provided by the complainants, complete the forms. WHD staff use the completed to obtain information about employer compliance with the provisions of the various labor standards laws enforced by the WHD and to determine if the agency has jurisdiction to investigate the alleged violation(s). WHD makes for form available in both English and Spanish. When the WHD schedules a complaint-based investigation, the agency makes the completed Form WH-3 part of the investigation case file.

US Code: 29 USC 1862(a) Name of Law: Migrant and Seasonal Agricultural Worker Protection Act
   US Code: 29 USC 2004(a)(3) Name of Law: Employee Polygraph Protection Act
   US Code: 29 USC 2616(a) Name of Law: Family and Medical Leave Act
   US Code: 15 USC 1676 Name of Law: Consumer Credit Protection Act
   US Code: 40 USC 3141 Name of Law: Davis Bacon Act
   US Code: 41 USC 38 Name of Law: Walsh-Healey Public Contracts Act
   US Code: 41 USC 353(a) Name of Law: McNamara-O'Hara Service Contract Act
   US Code: 29 USC 211(a) Name of Law: Fair Labor Standards Act
  
None

Not associated with rulemaking

  71 FR 70794 12/06/2006
72 FR 14614 03/28/2007
Yes

1
IC Title Form No. Form Name
Employment Information Form WH-3, WH-3 Sp Employment Information Form (Spanish) ,   Employment Information Form

  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 35,000 35,000 0 0 0 0
Annual Time Burden (Hours) 11,667 11,667 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$246,721
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Michel Smyth 202 693-0638 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/28/2007


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