Information Collection

Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)

IC 186913 under ICR 201410-1235-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (State, local, tribal) 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

View Information Collection (IC)

IC Title:	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	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 (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: 89,499	Number of Respondents for Small Entity: 70,488

Affected Public: State, Local, and Tribal Governments

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	4,198,798	2,128	-1,462,020	5,658,690
Annual IC Time Burden (Hours)	699,800	355	-1,764,986	2,464,431
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.