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 201202-1235-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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-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
WH-380-F Certification of Health Care Provider for Family Member WH-380-F (SHC Fam Member)[1].pdf www.dol.gov/whd/forms/WH-380-F.pdf Form and Instruction
WH-380-E Certification of Health Care Provider for Employee's Ser WH-380-E (SHC Ee)[1].pdf www.dol.gov/whd/forms/WH-380-E.pdf Form and Instruction
WH-384 Certification of Qualifying Exigency for Military Family WH-384 (Cert QEL)[1].pdf www.dol.gov/whd/forms/WH-384.pdf Form and Instruction
WH-385 Certification for Serious Injury or Illness of Covered S WH-385 (Cert Covered SM)[1].pdf www.dol.gov/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 825.305 29 CFR 825.100(d) 29 CFR 825.213(a)(3) 29 CFR 825.216(b) 29 CFR 825.310 29 CFR 825.312 29 CFR 825.309 29 CFR 825.306 29 CFR 825.307 29 CFR 825.308

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-F	Certification of Health Care Provider for Family Member Serious Health Condition	WH-380-F (SHC Fam Member)[1].pdf	http://www.dol.gov/whd/forms/WH-380-F.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-380-E	Certification of Health Care Provider for Employee's Serious Health Condition	WH-380-E (SHC Ee)[1].pdf	http://www.dol.gov/whd/forms/WH-380-E.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-384	Certification of Qualifying Exigency for Military Family Leave	WH-384 (Cert QEL)[1].pdf	http://www.dol.gov/whd/forms/WH-384.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-385	Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave	WH-385 (Cert Covered SM)[1].pdf	http://www.dol.gov/whd/forms/WH-385.pdf	Yes	No	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,133,519	15,500	12,118,019
Annual IC Time Burden (Hours)	4,029,986	7,750	4,022,236
Annual IC Cost Burden (Dollars)	163,632,730	300,545	163,332,185

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.