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

Family and Medical Leave Act of 1993, As Amended

⚠️ Notice: This information collection may be referencing outdated material.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 fillable.pdf www.dol.gov/whd/forms/WH-381.pdf Form and Instruction
WH-381 Notice of Eligibility and Rights and Responsibilities (F WH-381 (Rights and Responsibilities) 2014 draft.pdf www.dol.gov/whd/forms/WH-381.pdf Form and Instruction

Information Collection (IC) Details

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 fillable.pdf	http://www.dol.gov/whd/forms/WH-381.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-381	Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)	WH-381 (Rights and Responsibilities) 2014 draft.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: 291,000	Number of Respondents for Small Entity: 194,123

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	11,981,893	6,072	-4,172,094	16,147,915
Annual IC Time Burden (Hours)	1,996,982	1,012	-5,036,650	7,032,620
Annual IC Cost Burden (Dollars)	0	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.