Employment Information Form

Forms and Documents

Document Name	Status
Form WH-3-Sp Employment Information Form Form and Instruction	Modified
Justification 1235-0021.docx Justification for No Material/Nonsubstantive Change	2015-10-10
comment ext 20140708.pdf Supplementary Document	2014-10-07
ss1235-0021 (20141006).docx Supporting Statement A	2014-10-07

IC Document Collections

IC ID	Document Title	Status
13616	Employment Information Form Form and Instruction	Modified

ICR Details

OMB Control No: 1235-0021	ICR Reference No: 201510-1235-004
Status: Historical Active	Previous ICR Reference No: 201409-1235-001
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Employment Information Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/19/2015
	Date Received in OIRA: 10/17/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	12/31/2017	12/31/2017
Responses	35,350	0	35,350
Time Burden (Hours)	11,783	0	11,783
Cost Burden (Dollars)	0	0	0

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Abstract: WHD staff use Form WH-3 as a guide for obtaining information complainants (e.g., current and former employees, unions, and competitor employers) voluntarily provide about alleged violations of agency-administered labor standards. Complainants generally provide the information requested on the form to WHD staff over the telephone or in person. WHD staff use the information to determine whether the agency has jurisdiction to investigate the alleged violation(s). When the WHD schedules a complaint-based investigation, the agency makes the completed Form WH-3 part of the investigation case file. Where the information provided does not support a potential WHD enforcement action, complainants are advised and referred to the appropriate agency for further assistance.

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Authorizing Statute(s): US Code: 29 USC 211(a) Name of Law: Fair Labor Standards Act
   US Code: 29 USC 2004(a)(3) Name of Law: Employee Polygraph Protection Act
   US Code: 29 USC 2616(a) Name of Law: Family and Medical Leave Act
   US Code: 29 USC 1862(a) Name of Law: Migrant and Seasonal Agricultural Worker Protection Act
   US Code: 15 USC 1676 Name of Law: Consumer Credit Protection Act
   US Code: 40 USC 3141 Name of Law: Davis Bacon Act
   US Code: 41 USC 38 Name of Law: Walsh-Healey Public Contracts Act
   US Code: 41 USC 353(a) Name of Law: McNamara-O'Hara Service Contract Act
   US Code: 8 USC 1188(g) Name of Law: Immigration and Nationality Act
   EO: EO 13658 Name/Subject of EO: Establishing a Minimum Wage for Contractors
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1235-AA10	Not associated with rulemaking	79 FR 60634	10/07/2014

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 34568	06/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 34568	10/07/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Employment Information Form	WH-3, WH-3-Sp	Employment Information Form Spanish ,   Employment Information Form

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ICR Summary 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	35,350	35,350	0	0	0	0
Annual Time Burden (Hours)	11,783	11,783	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: President Obama issued Executive Order 13658 on February 12, 2014 requiring that the minimum wage be raised to $10.10 per hour for parties who perform work on or in connection with federal government contracts. The EO required the Department of Labor to issue regulations implementing the Order by October 1, 2014. The Department anticipates a slight increase in the number of complaints received as a result of the Executive Order and implementing regulations. As a result, the Department is submitting the ICR to update an increase in responses and burden hours.

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Annual Cost to Federal Government: $632,394

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/17/2015

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