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

Forms and Documents

Document	Type	Status	Availability
Form WH-382 Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified	Repair queued
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Modified	Repair queued
Form WH-382 Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	Form and Instruction	Modified	Repair queued
Form WH-380-F 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	Modified	Repair queued
Reclearance SupportStmnt 2011 FINAL.doc	Supporting Statement A	Uploaded 2011-12-19	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
187163	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)		Unchanged
187079	Notice to Employee of Pending Cancellation of Health Benefits (Federal)		Unchanged
187078	Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified
187073	Key Employee Notification (Federal)		Unchanged
186957	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)		Modified
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Modified
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified
186900	Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)		Unchanged
186899	Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Modified
186898	General FMLA Recordkeeping (Federal)		Unchanged
186891	Key Employee Notification (State, local, tribal)		Unchanged
186890	General FMLA Recordkeeping (State, local, tribal)		Unchanged
182234	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)		Unchanged
182233	Documenting Family Relationship		Modified
182083	Periodic Employee Status Report		Modified
182081	Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Modified
178656	General FMLA Recordkeeping (Private Sector)		Unchanged
178655	Key Employee Notification (Private Sector)		Unchanged
178653	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)		Modified
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	Modified
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	Modified

ICR Details

OMB Control No: 1235-0003	ICR Reference No: 201112-1235-003
Status: Historical Active	Previous ICR Reference No: 201003-1235-003
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: 29 C.F.R. 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: Approved without change	Conclusion Date: 02/09/2012
	Date Received in OIRA: 12/29/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	36 Months From Approved	02/29/2012
Responses	88,926,419	0	88,385,575
Time Burden (Hours)	19,009,201	0	18,969,645
Cost Burden (Dollars)	163,332,185	0	162,821,810

---

Abstract: The DOL created the subject information collections (i.e., notifications) to implement statutory notice and certification provisions and to assist employees and employers in meeting their FMLA third-party notification obligations as required by The Family and Medical Leave Act of 1993 (FMLA) and by the amendments to FMLA contained in National Defense Authorization Act for FY 2010 (NDAA), Pub. L. No. 111-84, and Airline Flight Crew Technical Corrections Act, Pub. L. No. 111-119. The subject recordkeeping requirements are necessary in order for the DOL to carry out its statutory obligation under FMLA section 106 to investigate and ensure employer compliance. 29 U.S.C. § 2616.

---

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

Citations for New Statutory Requirements: PL: Pub.L. 101 - 181 585(a)(s)-(3)(D) Name of Law: National Defense Authorization Act for Fiscal Year 2008
PL: Pub.L. 111 - 19 2 Name of Law: Airline Flight Crew Technical Corrections Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 60086	09/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 81981	12/29/2011
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 22

IC Title	Form No.	Form Name
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	WH-381	Notice of Eligibility and Rights and Responsibilities
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Key Employee Notification (State, local, tribal)
Key Employee Notification (Federal)
Periodic Employee Status Report
Notice to Employee of FMLA Designation (Private Sector)	WH-382	Designation Notice
Documenting Family Relationship
Employee's Notice of Need for FMLA Leave
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Key Employee Notification (Private Sector)
General FMLA Recordkeeping (Private Sector)
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-384, WH-380-F, WH-380-E, WH-385	Certification of Health Care Provider for Family Member Serious Health Condition ,   Certification of Health Care Provider for Employee's Serious Health Condition ,   Certification of Qualifying Exigency for Military Family Leave ,   Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	WH-381	Notice of Eligibility and Rights and Responsibilities
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
General FMLA Recordkeeping (State, local, tribal)
General FMLA Recordkeeping (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	WH-381	Notice of Eligibility and Rights and Responsibilities
Notice to Employee of FMLA Designation (State, local, tribal)	WH-382	Designation Notice
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Notice to Employee of FMLA Designation (Federal)	WH-382	Designation Notice

---

ICR Summary 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	88,926,419	88,385,575	540,844	0	0	0
Annual Time Burden (Hours)	19,009,201	18,969,645	39,556	0	0	0
Annual Cost Burden (Dollars)	163,332,185	162,821,810	510,375	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden increase is due to statutory changes in the National Defense Authorization Act for FY 2010 and the Airline Flight Crew Technical Corrections Act.

---

Annual Cost to Federal Government: $651,550

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? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 12/29/2011

---