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 201404-1235-001 · OMB 1235-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1235-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
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
WH-380-F Certification of Health Care Provider for Family Member WH-380-F (SHC Family).pdf www.dol.gov/whd/forms/WH-380-F.pdf	Form and Instruction
WH-380-E Certification of Health Care Provider for Employee's Ser WH-380-E (SHC Employee).pdf www.dol.gov/whd/forms/WH-380-E.pdf	Form and Instruction
WH-384 Certification of Qualifying Exigency for Military Family WH-384 (1-24-13).pdf www.dol.gov/whd/forms/WH-384.pdf	Form and Instruction
WH-385 Certification for Serious Injury or Illness of a Current WH-385 (1-24-13).pdf www.dol.gov/whd/forms/WH-385.pdf	Form and Instruction
WH-385-V Certification for a Serious Injury or Illness of a Veter WH385-V (1-24-13).pdf www.dol.gov/whd	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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 825.306 29 CFR 825.312 29 CFR 825.309

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	WH-380-F	Certification of Health Care Provider for Family Member Serious Health Condition	WH-380-F (SHC Family).pdf	http://www.dol.gov/whd/forms/WH-380-F.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-380-E	Certification of Health Care Provider for Employee's Serious Health Condition	WH-380-E (SHC Employee).pdf	http://www.dol.gov/whd/forms/WH-380-E.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-384	Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act)	WH-384 (1-24-13).pdf	http://www.dol.gov/whd/forms/WH-384.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-385	Certification for Serious Injury or Illness of a Current Servicemember for Military Family Leave (Family and Medical Leave Act)	WH-385 (1-24-13).pdf	http://www.dol.gov/whd/forms/WH-385.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-385-V	Certification for a Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)	WH385-V (1-24-13).pdf	www.dol.gov/whd	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,468,447

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,128,661	3,292	12,125,369
Annual IC Time Burden (Hours)	4,027,027	1,174	4,025,853
Annual IC Cost Burden (Dollars)	163,536,586	68,671	163,467,915

Documents for IC

table that charts IC Documents
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.