Information Collection

Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)

IC 178568 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction
WH-381 Notice of Eligibility and Rights and Responsibilities (F WH-381 (1-24-13).pdf www.dol.gov/whd/forms/WH-381.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	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 (Family and Medical Leave Act)	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: 216,352	Number of Respondents for Small Entity: 194,123

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,150,743	2,828	16,147,915
Annual IC Time Burden (Hours)	7,033,091	471	7,032,620
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.