Information Collection Request

Family and Medical Leave Act of 1993, As Amended

ICR 201410-1235-004 · OMB 1235-0003 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form WH-382 Designation Notice (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-382 Designation Notice (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-382 Designation Notice (Family and Medical Leave Act) Form and Instruction Modified Repair queued
Form WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-385-V Certification for Serious Injury or illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-380-F Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-385 Certification for Serious Injury or Illness of a Current Servicemember - - for Military Family Leave (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-384 Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act) Form and Instruction Modified Available
Form WH-380-E Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act) Form and Instruction Modified Available
WH-385-V (12-20-14),trk chg.pdf Supplementary Document Uploaded 2014-12-19 Available
WH-380-F (12-19-14), trk change.pdf Supplementary Document Uploaded 2014-12-19 Available
WH-380-E with GINA edits 4-7-15.docx Supplementary Document Uploaded 2015-04-09 Available
WH-385 (12-19-14), trk chg.pdf Supplementary Document Uploaded 2014-12-19 Available
FMLA 60day FR notice 9-11-14.pdf Supplementary Document Uploaded 2014-11-14 Available
employeeguide(3.26.13).pdf Supplementary Document Uploaded 2013-03-26 Available
ss1235-0003 20150215.docx Supporting Statement A Uploaded 2015-02-17 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
187163 Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal) Modified
187079 Notice to Employee of Pending Cancellation of Health Benefits (Federal) Unchanged
187078 Notice to Employee of FMLA Designation (Federal) Form and Instruction ModifiedDesignation Notice (Family and Medical Leave Act)
187073 Key Employee Notification (Federal) Modified
186957 Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal) Modified
186955 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction ModifiedNotice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
186913 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction ModifiedNotice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
186900 Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal) Modified
186899 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction ModifiedDesignation Notice (Family and Medical Leave Act)
186898 General FMLA Recordkeeping (Federal) Modified
186891 Key Employee Notification (State, local, tribal) Modified
186890 General FMLA Recordkeeping (State, local, tribal) Modified
182234 Notice to Employee of Pending Cancellation of Health Benefits (Private Sector) Modified
182233 Documenting Family Relationship Modified
182083 Periodic Employee Status Report Modified
182081 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction ModifiedDesignation Notice (Family and Medical Leave Act)
178656 General FMLA Recordkeeping (Private Sector) Modified
178655 Key Employee Notification (Private Sector) Modified
178653 Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector) Modified
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 ModifiedNotice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
178568 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction ModifiedNotice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
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 ModifiedCertification for Serious Injury or illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)
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 ModifiedCertification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act)
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 ModifiedCertification for Serious Injury or Illness of a Current Servicemember - - for Military Family Leave (Family and Medical Leave Act)
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 ModifiedCertification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act)
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 ModifiedCertification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act)

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
05/31/2018 36 Months From Approved 05/31/2015
82,371,724 0 89,305,469
9,313,503 0 19,027,093
184,932,912 0 163,467,915





Reginfo record details
22
table that charts list of burden
IC Title Form No. Form Name
Documenting Family Relationship
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-380-F, WH-385-V, WH-380-E ,   ,   ,   ,  
Employee's Notice of Need for FMLA Leave
General FMLA Recordkeeping (State, local, tribal)
General FMLA Recordkeeping (Federal)
General FMLA Recordkeeping (Private Sector)
Key Employee Notification (Federal)
Key Employee Notification (Private Sector)
Key Employee Notification (State, local, tribal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Designation (Federal) WH-382
Notice to Employee of FMLA Designation (Private Sector) WH-382
Notice to Employee of FMLA Designation (State, local, tribal) WH-382
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) WH-381, WH-381 ,  
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) WH-381
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) WH-381
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Periodic Employee Status Report

table that charts list 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 82,371,724 89,305,469 0 38,102 -6,971,847 0
Annual Time Burden (Hours) 9,313,503 19,027,093 0 4,918 -9,718,508 0
Annual Cost Burden (Dollars) 184,932,912 163,467,915 0 108,326 21,356,671 0


Reginfo record details
  No