Employment Information Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form WH-3-Sp Employment Information Form	Form and Instruction	Modified	Available
ss1235-0021 7-22-16 FINAL --- revised 12-19-2016 ss.doc	Supporting Statement A	Uploaded 2016-12-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13616	Employment Information Form	Form and Instruction	Modified

ICR Details

OMB Control No: 1235-0021	ICR Reference No: 201607-1235-003
Status: Historical Active	Previous ICR Reference No: 201605-1235-001
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Employment Information Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/21/2016
	Date Received in OIRA: 09/30/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	12/31/2017	12/31/2017
Responses	37,594	0	37,367
Time Burden (Hours)	12,531	0	12,456
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): 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
   EO: EO 13706 Name/Subject of EO: Establishing Paid Sick Leave for Contractors
   US Code: 29 USC 211(a) Name of Law: Fair Labor Standards Act
  

Citations for New Statutory Requirements: EO: EO 13706 Name/Subject of EO: Establishing Paid Sick Leave for Contractors

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1235-AA13	Final or interim final rulemaking	81 FR 67598	09/30/2016

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 9592	02/25/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 9592	02/25/2016
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

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

---

ICR Summary of Burden

table that charts list 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	37,594	37,367	227	0	0	0
Annual Time Burden (Hours)	12,531	12,456	75	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: This final rule creates a new entitlement to paid sick leave which is not currently required. As a result, more employees will have the right to file a complaint with the WHD to enforce their entitlement to paid sick leave.

---

Annual Cost to Federal Government: $669,607

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

---

Common Form ICR:  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:

(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: 09/30/2016

---