Information Collection Request

Family and Medical Leave Act of 1993, As Amended

ICR 201507-1235-001 · OMB 1235-0003 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction Unchanged Available
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction Unchanged Available
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction Unchanged Repair queued
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction Unchanged Repair queued
Form WH-382 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction Unchanged Available
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction Unchanged Available
Form WH-384 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 Modified Available
Justification for nonmaterial change 1235-0003.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-07-02 Available
WH-380-E 7-2-15.docx Supplementary Document Uploaded 2015-07-02 Available
WH-385-V (12-20-14),trk chg.pdf Supplementary Document Uploaded 2014-12-19 Repair queued
WH-380-F (12-19-14), trk change.pdf Supplementary Document Uploaded 2014-12-19 Available
WH-385 (12-19-14), trk chg.pdf Supplementary Document Uploaded 2014-12-19 Repair queued
FMLA 60day FR notice 9-11-14.pdf Supplementary Document Uploaded 2014-11-14 Repair queued
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
IC IDCollectionTypeStatusForm
187163 Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal) Unchanged
187079 Notice to Employee of Pending Cancellation of Health Benefits (Federal) Unchanged
187078 Notice to Employee of FMLA Designation (Federal) Form and Instruction Unchanged
187073 Key Employee Notification (Federal) Unchanged
186957 Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal) Unchanged
186955 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction Unchanged
186913 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction Unchanged
186900 Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal) Unchanged
186899 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction Unchanged
186898 General FMLA Recordkeeping (Federal) Unchanged
186891 Key Employee Notification (State, local, tribal) Unchanged
186890 General FMLA Recordkeeping (State, local, tribal) Unchanged
182234 Notice to Employee of Pending Cancellation of Health Benefits (Private Sector) Unchanged
182233 Documenting Family Relationship Unchanged
182083 Periodic Employee Status Report Unchanged
182081 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction Unchanged
178656 General FMLA Recordkeeping (Private Sector) Unchanged
178655 Key Employee Notification (Private Sector) Unchanged
178653 Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector) Unchanged
178607 Employee's Notice of Need for FMLA Leave Unchanged
178568 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction Unchanged
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 Modified
ICR Details
1235-0003 201507-1235-001
Historical Active 201410-1235-004
DOL/WHD
Family and Medical Leave Act of 1993, As Amended
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 07/16/2015
Retrieve Notice of Action (NOA) 07/09/2015
  Inventory as of this Action Requested Previously Approved
05/31/2018 05/31/2018 05/31/2018
82,371,724 0 82,371,724
9,313,503 0 9,313,503
184,932,912 0 184,932,912

The DOL created the subject information collections (i.e., notifications) to implement statutory notice and certification provisions and to assist employees and employers in meeting their FMLA third-party notification obligations as required by the Family and Medical Leave Act of 1993 (FMLA). The subject recordkeeping requirements are necessary in order for the DOL to carry out its statutory obligation under FMLA section 106 to investigate and ensure employer compliance. 29 U.S.C. § 2616.

US Code: 29 USC 2601, et seq. Name of Law: Family and Medical Leave Act
  
None

1235-AA09 Final or interim final rulemaking 80 FR 9989 02/25/2015

  79 FR 54299 11/11/2014
80 FR 10162 02/25/2015
Yes

22
IC Title Form No. Form Name
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Key Employee Notification (State, local, tribal)
Key Employee Notification (Federal)
Periodic Employee Status Report
Notice to Employee of FMLA Designation (Private Sector) WH-382 Designation Notice (Family and Medical Leave Act)
Documenting Family Relationship
Employee's Notice of Need for FMLA Leave
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Key Employee Notification (Private Sector)
General FMLA Recordkeeping (Private Sector)
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 Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act) ,   Certification for Serious Injury or Illness of a Current Servicemember - - for Military Family Leave (Family and Medical Leave Act) ,   Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act) ,   Certification for Serious Injury or illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act) ,   Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) WH-381, WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act) ,   Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
General FMLA Recordkeeping (State, local, tribal)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
General FMLA Recordkeeping (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
Notice to Employee of FMLA Designation (State, local, tribal) WH-382 Designation Notice (Family and Medical Leave Act)
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Notice to Employee of FMLA Designation (Federal) WH-382 Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)

  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 82,371,724 0 0 0 0
Annual Time Burden (Hours) 9,313,503 9,313,503 0 0 0 0
Annual Cost Burden (Dollars) 184,932,912 184,932,912 0 0 0 0
No
No
There is a slight increase upon existing responses, burden hours, and burden costs associated with this final rule. The changed paperwork burden estimates stem from two fundamental changes. First, the expansion of FMLA leave to employees to care for same-sex spouses and the stepchildren or stepparents of same-sex spouses, regardless of their state of residence. Second, increased wage rates for persons completing the information collections and other higher costs, as discussed in Item 13 of the supporting statement. The federal costs have also increased, in spite of utilizing double-sided printing, due to increases in postage prices. However, the respondents, responses, burden hours, and burden costs will now appear to be significantly lower than in the most recent FMLA rulemaking supporting statement. These changes principally stemmed from the Department's detection of the duplicative counting of respondents in an earlier rulemaking. This supporting statement has corrected those mathematical equations. Because some of those calculations result in different numbers of responses, burden hours and burden costs, the Department has carefully detailed the basis and steps to its current computations. Another change to this supporting statement, also for the purposes of clarity and transparency, is more clearly detailing the Department's attribution of hours and costs to employees, health care providers, and employers, respectively.

$784,860
No
No
No
No
No
Uncollected
robert waterman 202 693-0805 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/09/2015