Information Collection Request

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

ICR 201404-1235-001 · OMB 1235-0003 · Historical Inactive

Forms and Documents

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
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 Modified
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 Modified
186913 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction Modified
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 Modified
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 Modified
182083 Periodic Employee Status Report Unchanged
182081 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction Modified
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 Modified
178568 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction Modified
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 Modified

ICR Details

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table that charts list comparision
  Inventory as of this Action Requested Previously Approved
02/28/2015 02/28/2015 02/28/2015
89,305,469 0 89,305,469
19,027,093 0 19,027,093
163,467,915 0 163,467,915





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table that charts list of burden
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 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)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Key Employee Notification (State, local, tribal)
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)
General FMLA Recordkeeping (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)



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