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	Unchanged	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Unchanged	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Unchanged	Repair queued
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Unchanged	Repair queued
Form WH-382 Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Unchanged	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	Form and Instruction	Unchanged	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	Unchanged	Available
employeeguide(3.26.13).pdf	Supplementary Document	Uploaded 2013-03-26	Repair queued
Justification_for_non-subst_change_1235-0003.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-03-27	Repair queued
FMLA_Military_Guide_ENGLISH (Website).pdf	Supplementary Document	Uploaded 2013-03-14	Repair queued
FMLA Final Rule Gen Fact Sheet REVISED FINAL (Jan 2013).pdf	Supplementary Document	Uploaded 2013-03-14	Available
WH-385 (FR Update) TRACK CHANGES.docx	Supplementary Document	Uploaded 2013-01-23	Available
WH-381(07-11-12) Track Changes.docx	Supplementary Document	Uploaded 2013-01-23	Repair queued
WH-384 (07-12-12) Track Changes.docx	Supplementary Document	Uploaded 2013-01-23	Available
SupportStmnt.FMLA.FinRule-(1.25.12) FINAL CLEAN.docx	Supporting Statement A	Uploaded 2013-03-26	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	Unchanged
187073	Key Employee Notification (Federal)		Unchanged
186957	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)		Unchanged
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Unchanged
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Unchanged
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	Unchanged
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		Unchanged
182083	Periodic Employee Status Report		Unchanged
182081	Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Unchanged
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)		Unchanged
178607	Employee's Notice of Need for FMLA Leave		Unchanged
178568	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	Form and Instruction	Unchanged
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	Unchanged

ICR Details

OMB Control No: 1235-0003	ICR Reference No: 201303-1235-001
Status: Historical Active	Previous ICR Reference No: 201302-1235-001
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/11/2013
	Date Received in OIRA: 03/27/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	02/28/2015	02/28/2015
Responses	89,305,469	0	89,305,469
Time Burden (Hours)	19,027,093	0	19,027,093
Cost Burden (Dollars)	163,467,915	0	163,467,915

---

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:
1235-AA03	Final or interim final rulemaking	78 FR 8834	02/06/2013

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 8960	02/15/2012
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 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 Pending Cancellation of Health Benefits (Federal)
Key Employee Notification (State, local, tribal)
General FMLA Recordkeeping (Private Sector)
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)
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-385, WH-385-V, WH-380-F, WH-380-E	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 (Family and Medical Leave Act) ,   Certification for Serious Injury or Illness of a Current Servicemember for Military Family Leave (Family and Medical Leave Act) ,   Certification for a Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	WH-381	Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
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
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)

---

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	89,305,469	89,305,469	0	0	0	0
Annual Time Burden (Hours)	19,027,093	19,027,093	0	0	0	0
Annual Cost Burden (Dollars)	163,467,915	163,467,915	0	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: Compared to the last OMB clearance of the FMLA information collections on February 9, 2012, this request reflects an overall burden increase of 17,892 hours that results from proposed regulatory changes. In addition, this request reflects an increase of 379,050 responses, which also stem from proposed regulatory changes, and a difference of $135,730 in maintenance and operations costs. The changed paperwork burden estimates stem from the expansion of FMLA-leave to employees to care for covered veterans with serious injuries or illnesses; and increased wages rates for persons completing the information collections and other higher costs, as discussed in Item 13 of the supporting statement.

---

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: 03/27/2013

---