Employment Information Form

ICR 201303-1235-003

OMB: 1235-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2013-08-28
Supplementary Document
2013-06-19
Supporting Statement A
2013-08-23
IC Document Collections
IC ID
Document
Title
Status
13616 Modified
ICR Details
1235-0021 201303-1235-003
Historical Active 201007-1235-001
DOL/WHD
Employment Information Form
Extension without change of a currently approved collection   No
Regular
Approved without change 09/30/2013
Retrieve Notice of Action (NOA) 08/29/2013
  Inventory as of this Action Requested Previously Approved
09/30/2016 36 Months From Approved 09/30/2013
35,000 0 35,000
11,667 0 11,667
0 0 0

WHD staff use Form WH-3 as a guide for obtaining information complainants (e.g., current and former employees, unions, and competitor employers) voluntarily provide about alleged violations of agency-administered labor standards. Complainants generally provide the information requested on the form to WHD staff over the telephone or in person. WHD staff use the information to determine whether the agency has jurisdiction to investigate the alleged violation(s). When the WHD schedules a complaint-based investigation, the agency makes the completed Form WH-3 part of the investigation case file. Where the information provided does not support a potential WHD enforcement action, complainants are advised and referred to the appropriate agency for further assistance.

US Code: 29 USC 211(a) Name of Law: Fair Labor Standards Act
   US Code: 29 USC 1862(a) Name of Law: Migrant and Seasonal Agricultural Worker Protection Act
   US Code: 29 USC 2004(a)(3) Name of Law: Employee Polygraph Protection Act
   US Code: 29 USC 2616(a) Name of Law: Family and Medical Leave Act
   US Code: 15 USC 1676 Name of Law: Consumer Credit Protection Act
   US Code: 40 USC 3141 Name of Law: Davis Bacon Act
   US Code: 41 USC 38 Name of Law: Walsh-Healey Public Contracts Act
   US Code: 41 USC 353(a) Name of Law: McNamara-O'Hara Service Contract Act
   US Code: 8 USC 1188(g) Name of Law: Immigration and Nationality Act
  
None

Not associated with rulemaking

  78 FR 22912 04/17/2013
78 FR 54277 09/03/2013
No

1
IC Title Form No. Form Name
Employment Information Form WH-3, WH-3-Sp Employment Information Form Spanish ,   Employment Information Form

  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 35,000 35,000 0 0 0 0
Annual Time Burden (Hours) 11,667 11,667 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$622,640
No
No
No
No
No
Uncollected
Mary Ziegler 202 693-0517

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/29/2013


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