Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)

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⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

IC Title:	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.200(d)(1), (e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,950	Number of Respondents for Small Entity: 7,049

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,360,844	2,360,844
Annual IC Time Burden (Hours)	1,492	1,492
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.