Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)

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

⚠️ Notice: This information collection may be referencing outdated material.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-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction
WH-381 Notice of Eligibility and Rights and Responsibilities WH-381 (1-24-13).pdf www.dol.gov/whd/forms/WH-381.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.300(b), (c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	WH-381	Notice of Eligibility and Rights and Responsibilities	WH-381 (1-24-13).pdf	http://www.dol.gov/whd/forms/WH-381.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: 75,816	Number of Respondents for Small Entity: 70,488

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	5,658,690	1,816	5,656,874
Annual IC Time Burden (Hours)	2,464,431	303	2,464,128
Annual IC Cost Burden (Dollars)	0	0	0

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.