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 201207-1235-001 · OMB 1235-0003.

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Information Collection (IC) Details

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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 825.307 29 CFR 825.308 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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,461,097	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	Previously Approved
Annual Number of Responses for this IC	12,125,369	7,350	12,118,019
Annual IC Time Burden (Hours)	4,025,853	3,617	4,022,236
Annual IC Cost Burden (Dollars)	163,467,915	135,730	163,332,185

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.